A 22-year-old male presented with acute onset breathlessness, palpitations, profuse sweating, and vague chest discomfort for 1 hour. His ECG showed tachycardia at 200 bpm with a regular rhythm, right bundle branch block pattern, and extreme northwest axis. This case report discusses the differential diagnosis and criteria used to differentiate ventricular tachycardia from supraventricular tachycardia with aberrancy based on the ECG findings. Key criteria evaluated include Brugada criteria, AVR criteria, morphology, axis, and presence of fusion or capture beats. The conclusion is that while no single criteria is definitive, if there is any doubt the rhythm should be treated as ventricular tachycard

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