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Case Presentation
Dr.Ahmad Wali,
Resident Cardiology
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53 years old Female,K/c of HTN,Diabetes presented in cardiacemergency as having history of Chest pain 2 Hrs and thenunconsciousness. BP 80 mm Hg systolic, Pulse Not detected
Patient was given DC shock but she did not survive and expired.
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57 years old male,K/c of HTN,Diabetes presented in cardiacemergency as having Chest pain and Palpitation 2 HrsBP 110 mm Hg systolic, Pulse 70/min
The patient was given Amiodaron infusion and he got sinusRhythm.
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65 years old male diagnosed case of Decompensated HF presentedin cardiac emergency as having Chest pain,S.O.B 1 hrBP 110/80, Pulse 150/min,Bilateral Chest crepts presented.
The patient was given Amiodaron infusion and he gotsinus Rhythm.
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26 years old male who is smoker,alcoholic presented incardiac emergency as having Palpitation 1 hrBP 100/70, Pulse 150/min
The patient was given Amiodaron infusion with no improvementthen given 50 and 100 J DC Shock and he got the followingRhythm.
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All of the above fall in Wide
ComplexTachycardias so the D/Ds are b/w
Ventricular Tachycardia
SVT with aberrancy SVT with underlying bundle branch
block
SVT with pre-excitation(Wolf ParkinsonWhite Syndrome)
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Why it is important to Diagnose Wide complex
tacycardia??? Because correct diagnosis is important both for acute and also for later
management.
To avoid the use of Verapamil which may precipitate hemodynamiccollapse with V.T.
The clinical situation of the patient with WCT is usually serious so youdont have much time to read ECG ,so the criteria must be easilyapplied and easily remembered.
To use ECG criteria for diagnosis
To use presence of risk factors for V.T. as discriminator
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Definitions -WCT :Rate equal or more than 100 and QRS duration of at least 120
msec. -VT :a WCT starting below the level of His bundle.
-SVT : a tachycardia dependent on structures at or above the level ofHis bundle.
-LBBB morphology: QRS duration more than 120 with predominantlynegative terminal deflection in V1.
-RBBB morphology : QRS duration more than 120 and a terminalpositive deflection in V1. -LBBB and RBBB morphology denote the appearance of QRS , without
implying actual His-Purkinje disease.
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Definitions Aberrancy; conduction delay in His purkinji
system during antegrade conduction resulting
in wide QRS. Pre-exitation syndrome-AV conduction can
occure via normal conduction system and viaan accessory AV pathway.
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Wide-Complex Tachycardia If it's a wide complex rhythm (fast or slow) it's
ventricular until proven otherwise!The basic rule for WCT
Majority are sinus tachycardia with bundle branch block
In higher risk population , previous MI, Decreased Leftventricular dysfunction Predominantly Ventricular Tachycardia
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SVT vs VT
History
The majority of patients with VT have structuralheart disease, In SVT they may or may not have.
Patient with VT are older.
'Horizontal entrance' into the ER. Older patient withprevious M.I = most likely VT.
Younger patient with known paroxysmal
tachycardias and who is hemodynamically stable =most like SVT
-Patients with SVT more often have history ofprevious similar episodes .(cutoff of 3 years)
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SVT vs VT
Physical examination -Overall appearance of patient is not critical.
-The widespread impression that hemodynamic stability
indicates SVT is wrong and can lead to dangerous mistreatment.
-Physical findings that indicate presence of AV dissociation (variable-intensity S1,variation in BP unrelated to respiration) ifpresent are useful.
-Termination of WCT by maneuvers like Valsalva, carotid sinuspressure, or adenosine is strongly in-favor of SVT but there arewell-documented cases of VT responsive to these.
-Diagnostic injection of verapamil or beta-blockers should bediscouraged. (prolonged hypotension).
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What is WCT?It is refers to dysrhythmias with
rate greater than 100
beats/min associated with QRScomplex duration of more than0.12 sec
It is divided to:
=Regular
=Irregular
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Causes of WCT:
Irregular WCT:
Afib with BBB or IVCD (pre-existent or rate related)an example Asherman phenomenon
Afib with anterograde conduction over accessorypathway in WPW
Polymorphic VT ex: Torsades de pointes or due toDigitalis intoxication
Other causes of an irregular rhythm (A flutter withvariable conduction, ) with BBB, WPW, IVCD
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Causes of WCT:
Regular rhythm:
Ventricular driven rhythm:
VT : worst case scenario
Supraventricular rhythm with aberrant conduction:
SVT with BBB
SVT with accessory pathway Ex: WPW
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VT SVT withaberrancy
History Age>50Hx of MI, CHD, CABG, ASHD
Mitral valve prolapse
Previous Hx of VT
Mitral valve prolapse,s (WPW)
Previous Hx of SVT
Physicalexamination
Cannon A wave
Variation in arterial pulse
Variation in S1
Absence of variability
ECG Fusion beatsAV dissociation
QRS >0.14
Extreme LADNo response to vagal
maneuvers
Preceding P waves with QRS
QRS
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3 Most well accepted Criteria for WCT
Wellens criteria
Kindwalls criteria for VT in LBBB
Brugadas 4-step approach
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Wellens criteria
VT favored in the presence of
AV Dissociation
Left Axis Deviation Capture or Fusion Beats
QRS generally greater than 140 msec
Precordial QRS concordance
RSR in V1, mono- or biphasic QRS in V1, ormonophasic QS in V6
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Kindwalls ECG criteria for VT inLBBB.
R wave in V1 or V2 of >30 ms duration
Any Q wave in V6 Duration of >60 ms from the onset of the QRS
to the nadir of the S wave in V1 or V2
Notching on the downstroke of the S wave in
V1 or V2
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Brugada criteriaTable I.
Diagnosis Of Wide QRS Complex Tachycardia With A Regular Rhythm
Step 1. Is there absence of an RS complex in all precordial leads V1 V6?
If yes, then the rhythm is VT.
Sens 0.21 Spec 1.0Step 2. Is the interval from the onset of the R wave to the nadir of the S
wave greater than 100 msec in any precordial leads?
If yes, then the rhythm is VT.
Sens 0.66 Spec 0.98Step 3. Is there AV dissociation?
If yes, then the rhythm is VT.
Sens 0.82 Spec 0.98Step 4. Are morphology criteria for VT present? See Table II.
If yes, then the rhythm is VT.
Sens 0.99 Spec 0.97
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Morphology Criteria for VT
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R-wave to Peak Time 50ms in lead II strongly suggests VT
In 2010 Joseph Brugada published a new criterion to differentiate VT
from SVT in wide complex tachycardias.
Ultrasimple Brugada criterion
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Arrythmias in pre excitation orWPW syndrome
Regular mostly AVRT
Wide complex tachycardia
Irregularatrial arrythmias
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Management of WCT If the patient is hemodynamically unstable,
the first-choice therapy for ventriculartachycardia (VT) is synchronized direct-current (DC) cardioversion with 50 100 J
If the patient has a preserved heart function,the first-line treatment is lidocaine.
Alternatives include either amiodarone orprocainamide.
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If the patient has polymorphic VT with anormal baseline QT interval, AHA guidelinesstate that the first steps are to treat ischemia
and correct any electrolyte imbalance. If cardiac function is impaired, use
amiodaroneorlidocaine,followed bysynchronized DC cardioversion
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If the patient has polymorphic VT with aprolonged baseline QT interval, ACLS
guidelines state that any electrolyteimbalance should be corrected. Followingthis, any one of these treatments can beadministered: magnesium sulfate, overdrive
pacing, or lidocaine
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Long-term treatment of sustained ventriculararrhythmias includes placement of an
implantable cardioverter-defibrillator (ICD)and possible adjunctive therapy withamiodarone or sotalol. Patients should beunder the care of a cardiologist or
electrophysiologist
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Thank you