This document summarizes diagnostic algorithms for ventricular tachycardia (VT), including the Brugada algorithm and Vereckei algorithm. The Brugada algorithm uses three steps - absence of RS complex, R-S interval over 100ms, and checking for AV dissociation. The Vereckei algorithm only uses lead aVR and analyzes initial R wave dominance, QRS width over 40ms, notching, and V initial/V terminal ratio. The document also discusses differentiating VT from supraventricular tachycardia with aberrancy based on morphology, duration, and symptoms.

1. ARRHYTHMIA
CONFERENCE
Elino Meccar Moniem H
IM Resident 2nd Year
Southern Philippines Medical Center

2. Reference
s

3. Diagnosing
Ventricular Tachycardia
using
Brugada Algorithm
&
Vereckei Algorithm

4. Objectives
• To review the different types of tachycardia and their
differentials
• To discuss the diagnostic algorithm for Ventricular
Tachycardia: the Brugada Algorithm and Vereckei
Algorithm

11. Condori Leandro, H. I., Lebedev, D. S., & Mikhaylov, E. N. (2019).
Discrimination of ventricular tachycardia and localization of its
exit site using surface electrocardiography. Journal of geriatric
cardiology : JGC, 16(4), 362–377. doi:10.11909/j.issn.1671-
5411.2019.04.008

12. B Garner, J., & M Miller, J. (2013). Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That
Remains the Question. Arrhythmia & electrophysiology review, 2(1), 23–29.
https://doi.org/10.15420/aer.2013.2.1.23
1
•Absence of RS complex anywhere in V1–V6 = Ventricular
Tachycardia
2
•Onset of R to nadir of S in any precordial lead >100 ms =
Ventricular Tachycardia
3
•AV dissociation = Ventricular Tachycardia
4
•Morphology criteria
1
• An initial, dominant R in aVR = Ventricular Tachycardia
2
• An initial, non-dominant q or r in aVR >40 ms =
Ventricular Tachycardia
3
• Notching on an initial downstroke in aVR = Ventricular
Tachycardia
4
• Vt≥Vi in aVR = Ventricular Tachycardia
Brugada Algorithm Vereckei Algorithm

13. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. (1991) A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
;83:1649–59. [PubMed] [Google Scholar]
Step 1.
Absence of RS

18. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 1. Absence of RS = V T
If RS complex present, Proceed
to Step 2

19. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 2.
Is the R to S greater than 100ms?

20. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 2.
Is the R to S greater than 100ms?
Brugada Sign:
q to nadir of S > 100ms
Josephson
Sign: slurring of S
wave

23. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 2.
Is the R to S greater than 100ms?
If not, proceed to Step 3.

24. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 3.
Is there AV dissociation?

25. ECG 26

26. ECG 26
R to S > 100ms ? Is there AV D
Josephson Sign: slurring of

30. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation.
1991;83:1649–59. [PubMed] [Google Scholar]
Step 4.
Look for the Morphology Criteria

31. B Garner, J., & M Miller, J. (2013). Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That
Remains the Question. Arrhythmia & electrophysiology review, 2(1), 23–29.
https://doi.org/10.15420/aer.2013.2.1.23

34. B Garner, J., & M Miller, J. (2013). Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That
Remains the Question. Arrhythmia & electrophysiology review, 2(1), 23–29.
https://doi.org/10.15420/aer.2013.2.1.23
Predictive Values and Accuracies of the Most
Common Ventricular Tachycardia Criteria

35. B Garner, J., & M Miller, J. (2013). Wide Complex Tachycardia - Ventricular Tachycardia or Not Ventricular Tachycardia, That
Remains the Question. Arrhythmia & electrophysiology review, 2(1), 23–29.
https://doi.org/10.15420/aer.2013.2.1.23
1
•Absence of RS complex anywhere in V1–V6 = Ventricular
Tachycardia
2
•Onset of R to nadir of S in any precordial lead >100 ms =
Ventricular Tachycardia
3
•AV dissociation = Ventricular Tachycardia
4
•Morphology criteria
1
• An initial, dominant R in aVR = Ventricular Tachycardia
2
• An initial, non-dominant q or r in aVR >40 ms =
Ventricular Tachycardia
3
• Notching on an initial downstroke in aVR = Ventricular
Tachycardia
4
• Vt≥Vi in aVR = Ventricular Tachycardia
Brugada Algorithm Vereckei Algorithm

36. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. A new algorithm using only lead aVR for the differential diagnosis of
wide QRS complex tachycardia. Heart Rhythm. 2008;5:89–98. [PubMed] [Google Scholar]
Step 1.
Initial R wave in aVR

39. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. A new algorithm using only lead aVR for the differential diagnosis of
wide QRS complex tachycardia. Heart Rhythm. 2008;5:89–98. [PubMed] [Google Scholar]
Step 1.
Initial R wave in aVR
Present in our ECG

40. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. A new algorithm using only lead aVR for the differential diagnosis of
wide QRS complex tachycardia. Heart Rhythm. 2008;5:89–98. [PubMed] [Google Scholar]
If there is no
Initial R wave in aVR
Assess the width of
initial r wave or q wave > 40ms

41. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. A new algorithm using only lead aVR for the differential diagnosis of
wide QRS complex tachycardia. Heart Rhythm. 2008;5:89–98. [PubMed] [Google Scholar]
If the width of
initial r wave or q wave
doesn’t reach 1 small box
(40ms)
see the notching of initial downstroke

42. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. A new algorithm using only lead aVR for the differential diagnosis of
wide QRS complex tachycardia. Heart Rhythm. 2008;5:89–98. [PubMed] [Google Scholar]
If there’s no notching of
QRS downstroke
Compute for V initial / V terminal
A value of lesser than 1 = V
Tach

43. Harrison's Principles of Internal Medicine, 20th. ed. Author: Jameson, et. al.
Publisher: McGraw-Hill. Publish Year: 2018. Chapter 249 Page 1757

44. Harrison's Principles of Internal Medicine, 20th. ed. Author: Jameson, et. al.
Publisher: McGraw-Hill. Publish Year: 2018. Chapter 247 Page 1753

46. An example of SVT with Aberrancy

47. 1. VT according to Morphology
a. Monomorphic Ventricular Tachycardia
i. Rapid Bizarre wide QRS complex
ii. Appearance of all the beats match each other in each lead
b. Polymorphic Ventricular Tachycardia
i. Beat-to-beat variations in appearance
ii. Presents with an oscillating pattern mimicking the “turning of the
points” stitching pattern
2. VT according to Duration
a. Sustained Ventricular Tachycardia – ventricular tachycardia that lasts > 30
sec; or with hemodynamic compromise
b. Non-sustained VT – self-terminate within 30 sec (presence of at least >3
successive PVCs is considered VT)
3. VT Based on Symptoms
a. Pulseless VT – no effective cardiac output (no pulse no BP)
b. Stable VT – with pulse; no hypotension

48. Thank you