AHA GUIDELINES FOR VT SUMMARIZED

1. VENTRICULAR TACHYCARDIAS
Shirjeel Murtaza

2. V. TACHYCARDIA
• 3 or More consecutive QRS complexes of ventricular
origin at a rate of > 100 beats / min
• VTs arise distal to bifurcation of HIS bundle
• THREE MECHANISMs
– RE-ERNTRY (90 % VT with IHD)
– AUTOMATICITY ( escape rhythms, idiopathic VTs )
– TRIGGERED ( digitalis , catecholaminergic )

3. Some TERMS
• Sustained
– For More than 30 seconds
• Non Sustained
– For Less than 30 seconds
• Frequent PVCs
– > 5 / minute
– > 30 / hour
• Occasional PVCs

4. NOW WHAT TO DO ?

5. Wide Complex Tachycardias
• Any WCT in a patient with IHD is VT
• If you don’t know the reason, its VT
• Horizontal entry of patient in ER, is VT

6. Wide Complex Tachycardias
• Regular
– VT
– Abberant ventricular conduction
– Preexisting LBBB or RBBB
– Preexisting Nonspecific Intra ventricular conduction defects
– Anterograde conduction with pre excitation ( WPW with antedromic AVRT )
– Anterograde conduction over atriofascicular or nodo ventricular connection
• Irregular
– A Fib with abberant conduction/ BBB/ IVCD
– A fib with venricular pre excitation
– Polymorphic VT ( catecholaminergic )
– Torsade de Pointes

7. Differentiating points
VT
History of MI
AV dissociation ( Pathognomic )
Capture beats
Fusion beats
Extreme Axis
Very Broad complexes ( > 140 ms )
No response to Vagal manouvers or adenosine

8. Fusion beat• Marriot et al Criteria
1. Contour and Duration of QRS are intermediate
2. PR of Fusion < PR of supraventricular complex
3. PS (PJ) of Fusion > PR of supraventricular complex
4. Vector of Fusion complex is always different from
supraventricular
• EXCEPTIONs
– BBB/ IVCD/ SVT with variable Av conduction times

9. Capture beat
• Normal Contour
• Slightly pre mature

11. How to Assess a WCT
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

12. BRUGADA (1991)
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
SVT WITH ABBERANCY
RS100PM
Brugada’s sign

13. V1,2,6 Based Criteria
used by BRUGADA
• Wellens Criteria for VT-RBBB (1978)
– V1
• Monophasic R
• Biphasic qR, QR, RS
– V6
• rS , QS , qR
• Kindwall Criteria for VT-LBBB(1988)
– V1 & V2
• R > 30ms
– V1 & V2 Start of q to nadir of s > 60ms
– Notch on Downslop of S in V1 / V2
– Any Q in V6
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

14. V1,2,6 Based Criteria
used by BRUGADA
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
LBBB
• Delayed onset of intrinsicoid deflection in leads I, V5, V6
• Broad monophasic R waves in leads I, V5, V6 that are
usually notched or slurred
• rS or QS complex in right precordial leads
RBBB
• rsR’ or rSR
• Delayed onset of intrinsicoid deflection (beginning
of QRS to peak of R wave > 0.05 seconds) in V1
and V2
• Wide slurred S wave in leads I, V5, and V6

15. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
QRSP

16. Vereckei et al
aVR40nv

17. Wide Complex Tachycardias
• Any WCT in a patient with IHD is VT
• If you don’t know the reason, its VT
• Horizontal entry of patient in ER, is VT

18. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
STEP 1
STEP 2
Tip shows the origin

19. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

20. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

21. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

22. Special VT types

23. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
Lead iii ulti

24. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

25. • General Management
– Unstable
• DCC
– Synchronous for VT with pulse; Asynchronus for pulseless VT
– Stable
• Medical initiallly
• Search reversible cause and correct
– Ischemia
– Electrolyte imbalance
– Bradycardia
– Hypotension
– drugs
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

26. • Acute medical therapy
– Amiodarone ( agent of choice )
– Lidocaine ( ischemic origin )
– Procainamide
– B blockers ( for ACS, idiopathic RVOT )
– Calcium channel blockers ( RVOT, fascicular and digitalis )
– MgSO4 ( Torsade de pointes )
– Sodium Bicarbonate ( Acidosis ; TCA )
• RFA ( Curative for 90% of idiopathic VT )
• Surgical ablation ( for scar VT; with aneurysmectomy )
• ATP ( anti tachycardia pacing )
• Alcohol injection in coronary branch for the area
• Prevention
– B blockers ( primary )
– ICD ( primary and secondary )
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

27. Amiodarone
• Intravenous infusion
– Initial 5 mg/ kg over 20-120 minutes with ecg
monitoring; subsequent infusion given if necessary
according to response upto max. 1.2 g in 24 hours
• Pulseless VT or V fib. ( ACLS )
– Pre filled syringe or 300 mg diluted in 20 ml glucose 5
% after adrenaline if refractory to defibrillation.
Additional dose of 150 mg can be given by IV injection
if nececcary followed by infusion of 900 mg over 24
hours
Reference; BNF 67

28. Amiodaroone
• 5mg / kg bolus = 300 mg for 60 kg person
• INFUSION
– 1 mg / min for 6 hours
– ½ mg /min for 18 hours
24 hours
2 injections ( 300 mg ) in 100 ml burrette at 20 microdrops / min for 6 hours
then
At 10 microdrops for 18 hours

29. Amiodarone
• Oral
– Start: LOAD 800-1600mg PO qd x 1-3 wk until
response
• (for loading dose more than 1000mg / day divided w/
meals bid – tid)
– Maintenence
• 200-600 mg PO qd
• Divided bid-tid if GI intolerence

30. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

31. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

32. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT