II. Epidemiology

  1. Wide Complex Tachycardia in Children
    1. Presumptive Ventricular Tachycardia
  2. Wide Complex Tachycardia in Adults
    1. 75% of patients have Ventricular Tachycardia
    2. 90% of patients with CAD have VT
  3. References
    1. Akhtar (1988) Ann Intern Med 109:905-912 [PubMed]

III. Differential Diagnosis: Wide Complex Tachycardia

  1. Ventricular Tachycardia
    1. Safest to start treating as Ventricular Tachycardia (see Ventricular Tachycardia Management for precautions)
      1. No algorithm (e.g. Basel or Brugada as below) completely excludes Ventricular Tachycardia
    2. Criteria
      1. Tachycardia (Heart Rate >130, and typically >150 bpm) AND
      2. Wide QRS Complex (duration at least 0.12 sec)
      3. No P Wave to QRS Complex relationship (other than retrograde P Waves)
    3. Other findings suggestive of Ventricular Tachycardia
      1. Right bundle branch morphology of the QRS (RSR' or "rabbit ears")
        1. R Wave taller than the R' wave (Left rabbit ear taller than the right)
      2. Fusion Beats
        1. Supraventricular and ventricular waves fuse to form an irregular QRS
    4. References
      1. Mattu (2022) Crit Dec Emerg Med 36(5): 11
  2. Supraventricular Tachycardia with Aberrant Conduction
    1. Prior EKG demonstrating Left Bundle Branch Block
    2. QRS wide, regular and consistent across EKG leads
  3. Sinus Tachycardia with Aberrant Conduction

IV. Evaluation: Basel Algorithm for Wide Complex Tachycardia

  1. Criteria
    1. Clinical high risk features
      1. Myocardial Infarction
      2. Congestive Heart Failure with Reduced Ejection Fraction <35%
      3. Automated Implantable Defibrillator
    2. EKG findings
      1. Lead II Time to first peak >40 ms
      2. Lead aVR Time to first peak >40 ms
  2. Interpretation
    1. Ventricular Tachycardia is suggested by >1 of the above criteria
    2. SVT with aberrancy may be present if <=1 of the above criteria
  3. References
    1. Moccetti (2022) JACC Clin Electrophysiol 8(7): 831-9 +PMID: 35863808 [PubMed]

V. Evaluation: Brugada criteria for Wide Complex Tachycardia

  1. Only treat as SVT with aberrancy if ALL 4 criteria are absent
    1. Rule has a Test Sensitivity and Test Specificity >96% for VT
  2. Criteria (presence of any one of which suggests Ventricular Tachycardia)
    1. RS complex absent from all precordial leads
    2. R to S interval >100 ms in one precordial lead
    3. Atrioventricular Dissociation
    4. Morphologic criteria for Ventricular Tachycardia in leads V1, V2, V6
  3. References
    1. Brugada (1991) Circulation 83(5): 1649-59 [PubMed]

VI. Management: Acute Wide Complex Tachycardia

  1. New emphasis on use of choosing only one Antiarrhythmic
    1. Contrast to prior Antiarrhythmic soups
    2. Pro-arrhythmic effects increase with poly-drugs
  2. See Ventricular Tachycardia Management in the Adult
  3. See Ventricular Tachycardia Management in the Child

VII. Management: Chronic recurrent Ventricular Tachycardia

  1. Implantable Defibrillator (ICD)
    1. Long term best option (much better than meds)
    2. Efficacy: 40-50% reduction in sudden death
    3. References
      1. (1997) N Engl J Med 337:1576 [PubMed]
      2. Moss (1996) N Engl J Med 335:1933-40 [PubMed]
  2. Maximize Coronary Artery Disease management
    1. Bigger (1997) N Engl J Med 337:1569-75 [PubMed]

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