Rhythm diagnosis in regular wide complex tachycardia: Difference between revisions
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#Is there '''concordance'''(monophasic with same polarity) in all of the precordial leads? <ref>Brugada P et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991;83:1649-1659</ref> | #Is there '''concordance''' (monophasic with same polarity) in all of the precordial leads? <ref>Brugada P et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991;83:1649-1659</ref> | ||
##If yes then VT | ##If yes then VT | ||
##If no then continue | ##If no then continue |
Revision as of 23:40, 3 May 2014
Background
- Ventricular Tachycardia vs. Supraventricular Tachycardia
- Assume V-tach until proven otherwise
V-Tach vs. SVT
Factor |
V Tach | SVT w/ Aberrancy |
Age | >50 | <35 |
History | MI, CHF, CABG, MVR | MVR, WPW |
Cannon A Waves | Present | Absent |
Arterial Pulse | Variation | No variation |
First heart sound | Variable | Not variable |
Fusion Beats | Present | Absent |
AV dissociation | Present | Absent |
QRS | >0.14sec | <0.14sec |
Axis | Extreme LAD (< -30) | Normal or slightly abnl |
Vagal Maneuvers | No response | Slows or terminates |
QRS morphology (RBBB-like pattern) |
V1 - R or qR V6 - rS |
V1 - rsR' V6 - R(slurredS) |
QRS morphology (LBBB-like pattern) |
V1 or V2 - Broad R wave (>40msec) V6 - Any Q or QS |
V1 - rS or QS V6 - qRs |
Algorithms
- Only for regular rhythms
- Only for treatment decision if pt is stable
- Assume V-tach until proven otherwise
Brugada Algorithm
- Absence of an RS complex in all precordial leads?
- If yes then VT
- If no then continue
- RS interval >100ms in any precordial lead? (onset of R wave to deepest part of S wave)
- If yes then VT
- If no then continue
- AV dissociation?
- If yes then VT
- If no then continue
- Morphology criteria for v-tach present in both V1-2 and V6?
- If yes then VT
- If no then possibly SVT w/ aberrant conduction
aVR Algorithm
- In lead aVR:
- Presence of an initial R wave?
- If yes then VT
- If no then continue
- Presence of an initial r or q wave >40ms
- If yes then VT
- If no then continue
- Presence of a notch on descending limb of a negative onset, predominantly negative QRS?
- If yes then VT
- If no then continue
- Ventricular activation-velocity ratio (Vi/Vt) ≤1?
- If yes then VT
- If no then SVT
Niemann Algorithm
- Combination of the most specific aspects of the above two algorithms
Acronym: CARMA -> Concordance -> aVR ->Regular -> Morphology ->AV dissociation
- Presence of an initial R wave in aVR? [1][2]
- If yes then VT
- If no then continue
- Is there concordance (monophasic with same polarity) in all of the precordial leads? [3]
- If yes then VT
- If no then continue
- Is there evidence of AV dissociation?
- If yes then VT
- If no then continue
- Is the QRS morphology in V1 and V6 consistent with either LBBB or RBBB? [4][5]
- If no then VT
- If yes then SVT with aberrancy
R-Wave Peak Time
- In lead II, if the TIME in (ms) it takes the R wave to go from the isoelectric line to its peak voltage is greater than 50ms, it is VT. +LR 34.8
See Also
Source
- Brugada et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS Complex. Circulation, Vol 83, 1991.
- Vereckei et al. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia
- Niemann. Harbor-UCLA Grand Rounds
- Pava et al. R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias. Heart Rhythm. 2010 Jul;7(7):922-6
- ↑ Vereckei A et al. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachy- cardia. Heart Rhythm 2008; 5:89-98
- ↑ Szelenyi Z, et al. Acad Emerg Med 2013;20:1121- 1130
- ↑ Brugada P et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991;83:1649-1659
- ↑ Brugada, Circulation; Griffith MJ et al. Lancet 1994;343:386-388
- ↑ Wellens HJJ et al. Am J Med 1978; 64:27-33