Differential diagnosis of wide QRS complex tachycardia by ECG

Differential Diagnosis of wide QRS 
Complex Tachycardia by ECG 
Tran Tra Giang 
Hanoi Heart Hospital 
Introduction 
 A wide complex tachycardias (WCT) is defined as a rhythm 
with a rate >100/min with a QRS duration >120 ms. 
 The elucidation of the mechanism of WCT is vital not only 
for acute arrhythmia management, but also for the further 
work-up, prognosis and chronic management 
 Despite the published numerous ECG algorithms and 
criteria, the accurate, rapid diagnosis in patients with WCT 
remains a significant clinical problem, because many of 
these ECG criteria are complicated, not applicable in a 
large proportion of cases and difficult to recall in an urgent 
setting. 
Objective 
1. Evaluate some criteria in ECG of Ventricular Tachycardia. 
2. Evaluate the common Algorithms in differential diagnosis 
of WCT by ECG 
Method 
From 2008 to 8/2016,101 Patients (pts) with WCT 
were done diagnosis by EP study. 
 69 pts were diagnosised on VT 
 32 pts were diagnosised on SVT 
Review the ECG by the common Algorithms. 
Common Algorithms. 
 the Brugada Algorithm 
Vereckei Algorithm 
Griffith (Bundle Branch Block) algorithm 
Ultrasimple Pava criteria 
the Brugada Algorithm 
(Circulation. 1991;83(5):1649-59) 
VT 
Absence of an RS complex in all precordial 
leads 
yes 
No 
R to S interval > 100 ms in one precordial lead 
Yes 
VT 
No 
AV dissociation 
Morphology criteria for VT present both in 
precodial leads V1- V2 and V6 
Yes 
Yes 
No 
VT 
VT 
SVT 
Vereckei Algorithm 
(Heart Rhythm 2008) 
aVR Lead: 
Step 1 
Step 3 
Step 4 
Step 2 
Initial R wave in aVR present? 
 Initial R wave > 40 ms 
notching on the initialdownstroke of a 
predominantly negative QRS complex 
ventricular activation–velocity ratio Vi/Vt ≤ 1 
(-) 
(-) 
(-) 
VT 
VT 
VT 
VT 
(-) 
SVT 
(+) 
(+) 
(+) 
(+) 
Griffith Algorithm. 
 LBBB: rS or QS wave in leads V1 and V2, delay 
to S wave nadir < 70 ms, and R wave and no Q 
wave in lead V6 
RBBB: RSr' wave in lead V1 and an RS wave in 
lead V6, with R wave height greater than S wave 
depth 
Lancet. 1994 Feb12;343(8894):386-8 
Ultrasimple Pava criterion 
 the R wave peak time in Lead II. 
They suggest measuring the 
duration of onset of the QRS to 
the first change in polarity (either 
nadir Q or peak R) in lead II. If 
the RWPT is ≥ 50ms the 
likelihood of a VT very high. 
Heart Rhythm 2010 Jul;7(7):922-6 
Statistical analysis 
Occurrence of true as well as false-positive and 
negative results, as well as sensitivity and 
specificity 
SPSS for Windows (version 17.0, SPSS Inc., 
Chicago, IL, USA) was used for statistical 
analysis. P .05 value was considered significant. 
Patient characteristics 
SVT (n=32) 
VT (n=69) 
P 
Age (yrs, mean ±)SD 
36 ± 21 
49 ± 18 
<0,05 
Sex (male %) 
53,1% 
68,1% 
<0,05 
Structural heart 
diseases (%) 
6,2% 
15,9% 
<0,01 
Heart rate in 
tachycardia (c/min) 
156 ± 18 
178 ± 27 
<0,01 
P< 0.01 
SVT VT 
QRS interval in tachycardia 
ECG axis deviation 
SVT (n=32) 
VT (n=69) 
P 
Normal axis (%) 
46,9% 
2,9% 
<0,01 
Right axis (%) 
28,2% 
28,9 % 
NS 
Left axis (%) 
21,8% 
31,9% 
NS 
Extreme axis (%) 
3,1% 
36,3% 
<0,01 
AV dissociation 
11,6% 
Positive and negative concordance 
in the chest lead 
21,7% 
Josephson’s sign 
Notching near the nadir of the S wave 
Positive R in aVR 
40,5% 
3,1% 
P<0,01 
SVT VT 
QRS morphology in RBBB 
V1 
V6 
V1 
V6 
QRS morphology in LBBB 
SVT VT 
Sensitivity, specificity, and positive and 
negative predictive values of different 
Algorithms 
Sensitivity 
(95% CI) 
Specificity 
(95% CI) 
Positive 
predictive 
value (95% CI) 
Negative 
predictive 
value (95% CI) 
Vereckei 
95,6 (93,6-98,4) 
79,7 (64,7-94,2) 
94,2 (81,8-99,2) 
81,6 (68,1-91,2) 
Brugada 
88,6 (83,6-91,7) 
72,6 (67,4-77,6) 
89.5 (84.8–94.2) 
67,2 (58.9–75.5) 
Griffith 
73.2 (67.1–79.4) 
84.6 (77.2–90.8) 
89.1 (84.2–94.6) 
63.2 (55.1–71.8) 
Pava 
71.6 (67.5–77.8) 
83,2 (76.8–90.2) 
91.4(88,2–95.3) 
52,7 (45.1–60.4) 
Conclusion 
 Review quickly in ECG on WCT include 
extreme axis, positive R on aVR, 
concordance in chest lead, 
Josephson’sign may be suggested VT 
Vereckei algorithms is superior than other 
algorithms. 
Dr Michel Mirowski 
(1923-1990) 
Thank you for 
your attention 
ACC/AHA/ESC Algorithms. 
QRS morphology in precordial leads 
(A/V relationship is unknown) 
Typical RBBB 
Or LBBB SVT 
Precordial leads 
•Concordant 
•No R/S pattern VT 
•Onset or R to nadir 
Longger than 100 ms 
RBBB pattern 
•qR, Rs or Rr in V1 
•Frontal plane axis VT 
range from +90 
to -90 degrees 
LBBB pattern 
R in V1> 30 ms 
R to nadir of S in V1 VT 
>60 ms 
qR or qS in V6 
 Eur Heart J. 2003;24:1857–97.