1. K.M.JEYABALAJI
Dr.P. VIJAYARAGAVAN’S UNIT

2. HISTORY
 A 22 yr male patient came with complaints
of
 Acute onset breathlessness
 Palpitation
 Profuse sweating
 Vague chest discomfort
For past 1 hour

3. EXAMINATION
 Dyspnoeic, tachypnoeic,
 Pulse- 180/ min REGULAR
 BP- 90/ 60 mmhg
 JVP- ---
 CVS- s1,s2 heard
 RS – NVBS
 P/A- soft
 CNS- NFND

4. ADMISSION ECG

5. CHEST LEADS

6. FINDINGS
 TACHYCARDIA
 REGULAR RHYTM
 RATE- 200/min
 AXIS – EXTREME NORTH ( northwest)
 WIDE QRS COMPLEX
 RBBB PATTERN IN V1

7. DD FOR WIDE COMPLEX
TACHYCARDIA
• Ventricular tachycardia (VT)
• Supraventricular tachycardia
(SVT) with Aberrancy
• SVT with drug or electrolyte
induced QRS widening

8. APPROACH
WIDE COMPLEX TACHYCARDIA
REGULAR/IRREGULAR
AV DISSOCIATION
CLASSICAL BUNDLE BRANCH MORPHOLOGY
BRUGADA CRITERIA
AVR CRITERIA

9. BRUGADA CRITERIA
YES
Absence of RS complex in V1 – V6 VT
RS complex duration > 100 ms VT
AV dissociation VT
Morphology criteria VT

10. BRUGADA CRITERIA

11. MORPHOLOGY CRITERIA
For RBBB-type complexes
Is there an rSR’ morphology in V1?
Is there an RS complex in V6 (small
septal q OK)?
Is the R/S ratio in V6 > 1?
For LBBB-type complexes
Is there an rS or QS complex in V1 and V2?
Is the onset of the QRS to the nadir of the S in V1 < 70 ms?
Is there an R wave in lead V6 without a
Q?

12. AVR CRITERIA
 Presence of an initial R wave
 Width of an initial r or q wave >40 ms,
 Notching on the initial downstroke of a predominantly
negative QRS complex
 Ventricular activation–velocity ratio (vi/vt), the vertical
excursion (in millivolts) recorded during the initial (vi)
and terminal (vt) 40 ms of the QRS complex. When
any of criteria 1 to 3 was present, VT was diagnosed;
when absent, the next criterion was analyzed. In step
4, vi/vt >1 suggested SVT, and vi/vt ≤1 suggested VT.

14. VENTRICULAR TACHYCARDIA
 Absence of typical RBBB or LBBB morphology
 Extreme axis deviation (“northwest axis”)
 Very broad complexes (>160ms)
 AV dissociation (P and QRS complexes at different
rates)
 Capture beats — occur when the sinoatrial node
transiently ‘captures’ the ventricles, in the midst of AV
dissociation, to produce a QRS complex of normal
duration.
 Fusion beats — occur when a sinus and ventricular
beat coincides to produce a hybrid complex.

15.  Positive or negative concordance throughout the chest
leads, i.e. leads V1-6 show entirely positive (R) or
entirely negative (QS) complexes, with no RS
complexes seen.
 Brugada’s sign– The distance from the onset of the
QRS complex to the nadir of the S-wave is > 100ms
 Josephson’s sign – Notching near the nadir of the S-
wave

16. VT
CAPTURE BEAT FUSION BEAT
BRUGADA SIGN , JOSEPHSON SIGN

17. NEGATIVE CONCORDANCE POSITIVE CONCORDANCE

18. SVT WITH ABBERANCY
 • Any SVT can be conducted with aberrancy:
– Sinus Tachycardia
– Atrial tachycardia
– Atrial flutter
– Atrioventricular nodal reentrant tachycardia
(AVNRT)
– Junctional Tachycardia
– Orthodromic Atrioventricular Reentrant Tachycardia
(AVRT)

19. VT AGAINST VT
 Northwest axis  Hemodynamically stable
 Pseudo RBBB  No previous MI, CM
morphology  Vi/Vt > 1
 BRUGADA CRITERIA  No fusion, capture beat.
 AVR CRITERIA  no concordance
 Very broad QRS complex
> 160 ms

20. FASCICULAR VT
 SUPERIOR AXIS
 PSEUDO RBBB MORPHOLOGY
 HEMODYNAMICALLY STABLE

21. TAKE HOME MESSAGE
 No criteria is 100% sensitive nor specific
 Never go blindly by ECG
 Give equal imortance to history, clinical
presentation,
 Vitals
 If you are 100% sure that it is SVT, then
proceed.
 Having even 1% doubt, then treat it as VT

22. THANK YOU