Wide Complex Tachycardia

Aka: Wide Complex Tachycardia, Ventricular Tachycardia

1. See Also
   1. Ventricular Tachycardia Management in the Adult
   2. Ventricular Tachycardia Management in the Child
   3. Unstable Tachycardia
   4. Narrow Complex Tachycardia
2. 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]
3. 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]
4. 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
5. 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]
6. Management: Ventricular Tachycardia Storm
   1. Incidence: 10-20% of those with AICD
   2. Definition
      1. More than 3 sustained VF or VT or appropriate ICD shocks in 3 hours
      2. Sustained VT lasts >30 sec or hemodynamic compromise
   3. Evaluation
      1. Confirm Wide Complex Tachycardia (versus SVT with abberancy)
         1. Do not use Calcium Channel Blocker for wide complex unless absolutely certain of SVT
      2. Evaluate for secondary causes (e.g. infection, electrolytes, Creatinine, Hemoglobin, Troponin, drug levels)
      3. Confirm multiple appropriate shocks from AICD
         1. Deactivate device with magnet if inappropriate shocks
   4. Management
      1. Monomorphic VT (old MI scar)
         1. Amiodarone
         2. Beta Blockers
         3. Radiofrequency ablation (if preserved EF, at least >25%)
      2. Polymorphic VT with normal QT (MI within prior 72 hours)
         1. Coronary revascularization
      3. Polymorphic VT with Prolonged QT (Torsades de Pointes)
         1. Isoproterenol
         2. Over-drive pacing
         3. Magnesium
         4. Replace Potassium
      4. Ventricular Fibrillation: PVC-Initiated
         1. Radiofrequency ablation
      5. Ventricular Fibrillation: Brugada Syndrome
         1. Isoproterenol
         2. Quinidine (must be started before discontinuing Isoproterenol)
   5. References
      1. Roukoz (2018) Cardiac Arrhythmia Conference, UMN, Minneapolis