II. Epidemiology
- Wide Complex Tachycardia in Children
- Presumptive Ventricular Tachycardia
- Wide Complex Tachycardia in Adults
- 75% of patients have Ventricular Tachycardia
- 90% of patients with CAD have VT
- References
III. Differential Diagnosis: Regular Wide Complex Tachycardia
- Monomorphic Ventricular Tachycardia
- Precautions
- Safest to start treating as Ventricular Tachycardia (see Ventricular Tachycardia Management for precautions)
- No algorithm (e.g. Basel or Brugada as below) completely excludes Ventricular Tachycardia
- Safest to start treating as Ventricular Tachycardia (see Ventricular Tachycardia Management for precautions)
- Criteria
- Wide QRS Complex (duration at least 0.12 sec) for >=3 consecutive beats AND
- No P Wave to QRS Complex relationship (other than retrograde P Waves)
- Tachycardia (Heart Rate >130, and typically >150 bpm, may be as slow as 120 in some cases)
- VT rates may be <130 bpm with antidysrhythmics (e.g. Amiodarone, Sotalol, Flecainide)
- Slower rates 120-30 may also be due to Hyperkalemia, Sodium Channel Blocker Toxicity, AIVR
- Types
- Nonsustained: <30 seconds and no hemodynamic instability
- Sustained: >=30 seconds (or hemodynamic instability)
- Other findings suggestive of Ventricular Tachycardia
- QRS Complex duration >200 msec (almost always VT)
- Atrioventricular Dissociation (ventricular rate > atrial rate)
- Fusion Beats
- Supraventricular and ventricular waves fuse to form an irregular QRS
- Occur sporadically on the EKG
- Brugada Sign
- Time from start of QRS Complex to S wave lowest point (nadir) is >100 msec
- Josephson Sign
- Notching of the S wave downslope before its lowest point (nadir)
- QRS Complex concordance across the precordium
- Most or all leads V1-V6 have predominately positive or negative QRS Complexes
- Absence of a typical RBBB or LBBB
- Extreme axis deviation with QRS Axis between -90 and 180 degrees (northwest axis)
- Right bundle branch morphology of the QRS (RSR' or "rabbit ears")
- R Wave taller than the R' wave (Left rabbit ear taller than the right)
- References
- Berberian (2024) Crit Dec Emerg Med 38(2): 14-5
- Mattu (2022) Crit Dec Emerg Med 36(5): 11
- Precautions
-
Accelerated Idioventricular Rhythm (AIVR)
- Heart Rates typically 40 to 120 bpm
- Benign transient Dysrhythmia (typically lasts minutes and resolves)
- Occurs after coronary reperfusion (spontaneous or after PCI, Fibrinolysis)
- Differentiate from Ventricular Tachycardia which presents with Heart Rates >120-130
- Observation of suspected AIVR rhythm only
- Antidromic Atrioventricular Reciprocating Tachycardia (AVRT)
- Paroxysmal Supraventricular Tachycardia (30% of cases) with an accessory pathway (outside the AV Node)
- Aberrant Conduction
- Causes
- Left or Right Bundle Branch Block
- Metabolic abnormalities
- Hyperkalemia
- Ventricular paced rhythm
- Ventricular Preexcitation (e.g. WPW)
- Sodium Channel Blocker Toxicity (Acute Poisoning)
- AVR with dominant R Wave or R/S Wave >0.7
- P Waves may be subtle (but are often present)
- Critical to identify as repeated doses of Sodium Bicarbonate (until QRS narrows) is life saving
- Rhythms
- Sinus Tachycardia with Aberrant Conduction
- Supraventricular Tachycardia with Aberrant Conduction
- Prior EKG demonstrating Left Bundle Branch Block
- QRS wide, regular and consistent across EKG leads
- Causes
IV. Evaluation: Basel Algorithm for Wide Complex Tachycardia
- Criteria
- Clinical high risk features
- Myocardial Infarction
- Congestive Heart Failure with Reduced Ejection Fraction <35%
- Automated Implantable Defibrillator
- EKG findings
- Lead II Time to first peak >40 ms
- Lead aVR Time to first peak >40 ms
- Clinical high risk features
- Interpretation
- Ventricular Tachycardia is suggested by >1 of the above criteria
- SVT with aberrancy may be present if <=1 of the above criteria
- References
V. Evaluation: Brugada criteria for Wide Complex Tachycardia
- Only treat as SVT with aberrancy if ALL 4 criteria are absent
- Rule has a Test Sensitivity and Test Specificity >96% for VT
- Criteria (presence of any one of which suggests Ventricular Tachycardia)
- RS complex absent from all precordial leads
- R to S interval >100 ms in one precordial lead
- Atrioventricular Dissociation
- Morphologic criteria for Ventricular Tachycardia in leads V1, V2, V6
- References
VI. Management: Acute Wide Complex Tachycardia
- Electrical cardioversion is the safest and most effective strategy in wide complex tachydysrhthmia
- In contrast, with antiarrhthmics, many wide Tachycardias (e.g. Prolonged QTc, Brugada) degenerate into Cardiac Arrest
- New emphasis on use of choosing only one Antiarrhythmic
- Contrast to prior Antiarrhythmic soups
- Pro-arrhythmic effects increase with Polypharmacy
- Procainamide is most effective of the Antiarrhythmics for stable Monomorphic Ventricular Tachycardia
- Stable Monomorphic Ventricular Tachycardia (avoid in Prolonged QTc, Brugada Syndrome)
- See Ventricular Tachycardia Management in the Adult
- See Ventricular Tachycardia Management in the Child
VII. Management: Chronic recurrent Ventricular Tachycardia
-
Implantable Defibrillator (ICD)
- Long term best option (much better than meds)
- Efficacy: 40-50% reduction in sudden death
- References
- Maximize Coronary Artery Disease management
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Related Studies
| Definition (NCI) | A disorder characterized by an electrocardiographic finding of three or more consecutive complexes of ventricular origin with a rate greater than a certain threshold (100 or 120 beats per minute are commonly used). The QRS complexes are wide and have an abnormal morphology. (CDISC) |
| Definition (NCI_CTCAE) | A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates distal to the bundle of His. |
| Definition (NCI_FDA) | An abnormally rapid ventricular rhythm with aberrant ventricular excitation, usually in excess of 150 beats per minute. |
| Definition (MSH) | An abnormally rapid ventricular rhythm usually in excess of 150 beats per minute. It is generated within the ventricle below the BUNDLE OF HIS, either as autonomic impulse formation or reentrant impulse conduction. Depending on the etiology, onset of ventricular tachycardia can be paroxysmal (sudden) or nonparoxysmal, its wide QRS complexes can be uniform or polymorphic, and the ventricular beating may be independent of the atrial beating (AV dissociation). |
| Concepts | Pathologic Function (T046) |
| MSH | D017180 |
| ICD10 | I47.2 |
| SnomedCT | 195075005, 6624005, 155370003, 25569003 |
| English | Tachycardia, Ventricular, TACHYCARDIA VENTRICULAR, Tachycardias, Ventricular, Ventricular Tachycardias, Ventricular Tachycardia, ventricular tachycardia (diagnosis), ventricular tachycardia, V.tach, Tachycardia ventricular, Tachycardia, ventricular, Tachycardia, Ventricular [Disease/Finding], v tach, vt, ventricular tachyarrhythmia, ventricular tachycardia (V-tach), Ventricular tachycardia (Vtach), Tachycardia - ventric., Ventricular tachyarrhythmia (disorder), Ventricular techycardia, VENTRICULAR TACHYCARDIA, Ventricular tachycardia, VT - Ventricular tachycardia, Ventricular tachycardia (disorder), Ventricular tachyarrhythmia, tachycardia; ventricular, ventricular; tachycardia, Ventricular tachycardia, NOS, Tachycardia;ventricular |
| French | TACHYCARDIE VENTRICULAIRE, Tachyarythmie ventriculaire, V.tach, Tachycardie ventriculaire |
| Portuguese | TAQUICARDIA VENTRICULAR, Taquiarritmia ventricular, Taquicardia ventricular, Taquicardia Ventricular |
| Spanish | TAQUICARDIA VENTRICULAR, Taquiarritmia ventricular, Taquicardia V, taquiarritmia ventricular, taquiarritmia ventricular (trastorno), taquicardia ventricular (trastorno), taquicardia ventricular, Taquicardia ventricular, Taquicardia Ventricular |
| Dutch | ventriculaire tachyaritmie, ventrikeltachycardie, tachycardie; ventriculair, ventriculair; tachycardie, ventriculaire tachycardie, Ritmestoornis, Tachycardie, ventriculaire, Ventriculaire tachycardie |
| German | Kammer-Tachyarrhythmie, V.tach, TACHYKARDIE VENTRIKULAER, Ventrikulaere Tachykardie, Tachykardie ventrikulaer, Tachykardie, ventrikuläre |
| Italian | Tachiaritmia ventricolare, Tachicardia ventricolare |
| Japanese | 心室性頻脈性不整脈, ｼﾝｼﾂｾｲﾋﾝﾐｬｸ, ｼﾝｼﾂｾｲﾋﾝﾐｬｸｾｲﾌｾｲﾐｬｸ, 心室性頻拍, 頻拍-心室性, 心室性頻拍症, 心室性頻脈, 心室頻拍, 心室頻拍症, 心室頻脈, 発作性心室性頻拍, 発作性心室性頻拍症, 発作性心室頻拍, 発作性心室頻拍症 |
| Swedish | Kammartakykardi |
| Finnish | Kammiotakykardia |
| Russian | TAKHIKARDIIA VENTRIKULIARNAIA, TAKHIKARDIIA ZHELUDOCHKOVAIA PAROKSIZMAL'NAIA, ТАХИКАРДИЯ ВЕНТРИКУЛЯРНАЯ, ТАХИКАРДИЯ ЖЕЛУДОЧКОВАЯ ПАРОКСИЗМАЛЬНАЯ |
| Czech | Ventrikulární tachyarytmie, Tachykardie komorová, Komorová tachykardie, KT, VT, komorová tachykardie, tachykardie komorová |
| Korean | 심실성 빠른맥 |
| Croatian | TAHIKARDIJA, VENTRIKULARNA |
| Polish | VT, Tachykardia komorowa, Częstoskurcz komorowy |
| Hungarian | Ventricularis tachyarrhythmia, Tachycardia,ventricularis, V . Tach., Ventricularis tachycardia |
| Norwegian | Ventrikkeltakykardi, Takykardi, ventrikkel-, Ventrikulær takykardi |
Ontology: Ventricular tachycardia, monomorphic (C0344431)
| Definition (NCI_CDISC) | An electrocardiographic finding of a ventricular tachycardia in which the QRS complexes have a uniform morphology. |
| Definition (NCI) | An electrocardiographic finding of a ventricular tachycardia in which the QRS complexes have a uniform morphology. (CDISC) |
| Concepts | Disease or Syndrome (T047) |
| SnomedCT | 251158004 |
| English | Ventricular tachy, monomorphic, Ventricular Tachycardia, Monomorphic, Monomorphic Ventricular Tachycardia by EKG Finding, VENTRICULAR TACHYCARDIA, MONOMORPHIC, Monomorphic Ventricular Tachycardia, Monomorphic Ventricular Tachycardia by ECG Finding, Monomorphic ventricular tachycardia, Ventricular tachycardia, monomorphic, Ventricular tachycardia, monomorphic (disorder) |
| Dutch | monomorfe ventriculaire tachycardie |
| French | Tachycardie ventriculaire monomorphe |
| German | monomorphe ventrikulaere Tachykardie |
| Italian | Tachicardia ventricolare monomorfa |
| Portuguese | Taquicardia ventricular monomórfica |
| Spanish | Taquicardia ventricular monomórfica, taquicardia ventricular, monomorfa (trastorno), taquicardia ventricular, monomorfa |
| Japanese | 単形性心室頻脈, ﾀﾝｹｲｾｲｼﾝｼﾂﾋﾝﾐｬｸ |
| Czech | Monomorfní komorová tachykardie |
| Hungarian | Monomorph ventricularis tachycardia |
