Case Presentation

Dr.Ahmad Wali, Resident Cardiology

53 years old Female,K/c of HTN,Diabetes presented in cardiac emergency as having history of Chest pain 2 Hrs and then unconsciousness. BP 80 mm Hg systolic, Pulse Not detected

Patient was given DC shock but she did not survive and expired.

57 years old male,K/c of HTN,Diabetes presented in cardiac emergency as having Chest pain and Palpitation 2 Hrs BP 110 mm Hg systolic, Pulse 70/min

The patient was given Amiodaron infusion and he got sinus Rhythm.

65 years old male diagnosed case of Decompensated HF presented in cardiac emergency as having Chest pain,S.O.B 1 hr BP 110/80, Pulse 150/min,Bilateral Chest crepts presented.

The patient was given Amiodaron infusion and he got sinus Rhythm.

26 years old male who is smoker,alcoholic presented in cardiac emergency as having Palpitation 1 hr BP 100/70, Pulse 150/min

The patient was given Amiodaron infusion with no improvement then given 50 and 100 J DC Shock and he got the following Rhythm.

All of the above fall in Wide ComplexTachycardias so the D/Ds are b/w

Ventricular Tachycardia SVT with aberrancy SVT with underlying bundle branch block SVT with pre-excitation(Wolf Parkinson White Syndrome)

Why it is important to Diagnose Wide complex tacycardia???

Because correct diagnosis is important both for acute and also for later management. To avoid the use of Verapamil which may precipitate hemodynamic collapse with V.T.

The clinical situation of the patient with WCT is usually serious so you dont have much time to read ECG ,so the criteria must be easily applied and easily remembered.
To use ECG criteria for diagnosis To use presence of risk factors for V.T. as discriminator

Definitions

-WCT :Rate equal or more than 100 and QRS duration of at least 120 msec. -VT :a WCT starting below the level of His bundle. -SVT : a tachycardia dependent on structures at or above the level of His bundle.

-LBBB morphology: QRS duration more than 120 with predominantly negative terminal deflection in V1.
-RBBB morphology : QRS duration more than 120 and a terminal positive deflection in V1. -LBBB and RBBB morphology denote the appearance of QRS , without implying actual His-Purkinje disease.

Definitions

Aberrancy; conduction delay in His purkinji system during antegrade conduction resulting in wide QRS. Pre-exitation syndrome-AV conduction can occure via normal conduction system and via an accessory AV pathway.

Wide-Complex Tachycardia

If it's a wide complex rhythm (fast or slow) it's ventricular until proven otherwise! The basic rule for WCT

Majority are sinus tachycardia with bundle branch block In higher risk population , previous MI, Decreased Left ventricular dysfunction Predominantly Ventricular Tachycardia

SVT vs VT History

The majority of patients with VT have structural heart disease, In SVT they may or may not have. Patient with VT are older. 'Horizontal entrance' into the ER. Older patient with previous M.I = most likely VT. Younger patient with known paroxysmal tachycardias and who is hemodynamically stable = most like SVT -Patients with SVT more often have history of previous similar episodes .(cutoff of 3 years)

SVT vs VT Physical examination

-Overall appearance of patient is not critical. -The widespread impression that hemodynamic stability indicates SVT is wrong and can lead to dangerous mistreatment. -Physical findings that indicate presence of AV dissociation ( variable-intensity S1,variation in BP unrelated to respiration) if present are useful. -Termination of WCT by maneuvers like Valsalva, carotid sinus pressure, or adenosine is strongly in-favor of SVT but there are well-documented cases of VT responsive to these. -Diagnostic injection of verapamil or beta-blockers should be discouraged. (prolonged hypotension).

What is WCT?
It is refers to dysrhythmias with rate greater than 100 beats/min associated with QRS complex duration of more than 0.12 sec
It is divided to: =Regular =Irregular

Causes of WCT:
Irregular WCT: Afib with BBB or IVCD (pre-existent or rate related) an example Asherman phenomenon

Afib with anterograde conduction over accessory pathway in WPW Polymorphic VT ex: Torsades de pointes or due to Digitalis intoxication Other causes of an irregular rhythm (A flutter with variable conduction, ) with BBB, WPW, IVCD

Causes of WCT:
Regular rhythm: Ventricular driven rhythm: VT : worst case scenario

Supraventricular rhythm with aberrant conduction: SVT with BBB SVT with accessory pathway Ex: WPW

VT
History
Age>50 Hx of MI, CHD, CABG, ASHD Mitral valve prolapse Previous Hx of VT Cannon A wave Variation in arterial pulse Variation in S1 Fusion beats AV dissociation QRS >0.14 Extreme LAD No response to vagal maneuvers

SVT with aberrancy

Mitral valve prolapse,s (WPW) Previous Hx of SVT

Physical examinatio n ECG

Absence of variability

Preceding P waves with QRS QRS <0.14 Normal axis Slow or terminate with vagal maneuvers

3 Most well accepted Criteria for WCT

Wellens criteria Kindwalls criteria for VT in LBBB Brugadas 4-step approach

Wellens criteria
VT favored in the presence of AV Dissociation Left Axis Deviation Capture or Fusion Beats QRS generally greater than 140 msec Precordial QRS concordance RSR in V1, mono- or biphasic QRS in V1, or monophasic QS in V6

Kindwalls ECG criteria for VT in LBBB.

R wave in V1 or V2 of >30 ms duration Any Q wave in V6 Duration of >60 ms from the onset of the QRS to the nadir of the S wave in V1 or V2 Notching on the downstroke of the S wave in V1 or V2

Brugada criteria
Table I. Diagnosis Of Wide QRS Complex Tachycardia With A Regular Rhythm
Step 1. Is there absence of an RS complex in all precordial leads V1 V6?

If yes, then the rhythm is VT.

Step 2.

Sens 0.21 Spec 1.0

Is the interval from the onset of the R wave to the nadir of the S wave greater than 100 msec in any precordial leads?

If yes, then the rhythm is VT. Sens 0.66 Spec 0.98

Step 3.

Is there AV dissociation?
If yes, then the rhythm is VT.

Step 4.

Sens 0.82 Spec 0.98

Are morphology criteria for VT present? See Table II.

If yes, then the rhythm is VT.

Sens 0.99 Spec 0.97

Morphology Criteria for VT

Ultrasimple Brugada criterion

R-wave to Peak Time 50ms in lead II strongly suggests VT In 2010 Joseph Brugada published a new criterion to differentiate VT from SVT in wide complex tachycardias.

Arrythmias in pre excitation or WPW syndrome

Regular mostly AVRT Wide complex tachycardia Irregular atrial arrythmias

Management of WCT

If the patient is hemodynamically unstable, the first-choice therapy for ventricular tachycardia (VT) is synchronized directcurrent (DC) cardioversion with 50 100 J If the patient has a preserved heart function, the first-line treatment is lidocaine. Alternatives include either amiodarone or procainamide.

If the patient has polymorphic VT with a normal baseline QT interval, AHA guidelines state that the first steps are to treat ischemia and correct any electrolyte imbalance. If cardiac function is impaired, use amiodarone or lidocaine, followed by synchronized DC cardioversion

If the patient has polymorphic VT with a prolonged baseline QT interval, ACLS guidelines state that any electrolyte imbalance should be corrected. Following this, any one of these treatments can be administered: magnesium sulfate, overdrive pacing, or lidocaine

Long-term treatment of sustained ventricular arrhythmias includes placement of an implantable cardioverter-defibrillator (ICD) and possible adjunctive therapy with amiodarone or sotalol. Patients should be under the care of a cardiologist or electrophysiologist

Thank you