A 22-year-old male presented with acute onset breathlessness, palpitations, and profuse sweating. His ECG showed tachycardia at a rate of 200 bpm with a right bundle branch block pattern. This wide complex tachycardia was determined to be ventricular tachycardia based on Brugada criteria and AVR criteria, including the absence of an RS complex in leads V1-V6, a QRS duration greater than 100 ms, and a ventricular activation-velocity ratio greater than 1. The patient was diagnosed with ventricular tachycardia based on the ECG findings and treated accordingly.

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 (v i /v t ), the vertical excursion (in millivolts) recorded during the initial (v i ) and terminal (v t ) 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, v i /v t >1 suggested SVT, and v i /v t ≤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 Pseudo RBBB morphology BRUGADA CRITERIA AVR CRITERIA Very broad QRS complex > 160 ms Hemodynamically stable No previous MI, CM Vi/Vt > 1 No fusion, capture beat. no concordance

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