The document defines irregular wide complex tachycardias, highlighting causes such as polymorphic ventricular tachycardia and atrial fibrillation with aberrant conduction. It details the characteristics and mechanisms of torsades de pointes, a specific form of polymorphic VT, and discusses various types including catecholaminergic polymorphic VT and bi-directional VT. Additionally, it outlines the impact of atrial fibrillation and ventricular fibrillation on heart rhythms.

1. IRREGULAR WIDE
COMPLEX
TACHYCARDIAS

2. DEFINITION
1. Varying R-R Interval
2. QRS complex duration >.12 secs

3. Causes of wide QRS
Irregular Tachycardia:
• Polymorphic ventricular tachycardia
• Pre-excited Atrial Fibrillation and Atrial
fibrillation with aberrant conduction
• Atrial Flutter With Aberrant Conduction

4. Polymorphic VT
• It may be sustained or non-sustained
• Initial complexes in monomorphic VT may often show
irregularities of rhythm. Therefore, the conclusion should be
made when VT is established
• Polymorphic VT includes :

5. TORSADES DE POINTES
• Torsade de pointes is an uncommon and distinctive form of polymorphic
ventricular tachycardia (VT) characterized by a gradual change in the amplitude
and twisting of the QRS complexes around the isoelectric line.
• In torsade, the morphology of the QRS complexes varies from beat to beat. The
ventricular rate can range from 150 beats per minute (bpm) to 250 bpm.
• The definition also requires that the QT interval be increased markedly (often to
≥600 msec)
• Use of group IA antidysrhythmic drugs, which tend to prolong the QT interval,
can have disastrous consequences in torsade
• There are 2 types of torsos de pointes polymorphic VT
1. Classical VT
2. Familiar polymorphic VT

6. • The most consistent indicator of QT prolongation is a QT of
0.60 s or longer or a QTc (corrected for heart rate) of 0.45 s
or longer.
• Patients have paroxysms of 5-20 beats at a rate faster than
200 bpm; sustained episodes occasionally can be seen
• Progressive change in polarity of QRS about the isoelectric
line occurs
• Complete 180° twist of QRS complexes in 10-12 beats is
present
• A short-long-short sequence between the R-R intervals
occurs before the trigger response.
• Patients may revert spontaneously or convert to a
nonpolymorphic ventricular tachycardia or ventricular
fibrillation
• Occasionally, T-wave alternans may be seen before torsade

7. TORSADES DE POINTES

8. Pleomorphic VT
• Occasionally sustained VT in alternate
morphologies[pleomorphism] such as RBBB and
LBBB. These may be gradual or abrupt.
• These changes may be gradual or abrupt, and occur
over long or short periods of time.
• Morphologies are considered to be different when
they have different patterns [RBBB or LBBB], or when
QRS deviation changes to more or equal to
45degress, even if the bundle branch block pattern is
unchanged

10. Bi-Directional VT
• Bi- Directional tachycardias are infrequent or may be
supra ventricular [BSVT] or ventricular[DVT] origin.
• The frontal plane axis [AQRS] shows alternative
changes of approximately 180 degrees
• RR intervals are usually equal but sometimes show
bi geminal pattern.

12. Catecholeminergic
polymorphic VT
• This type of VT is a infrequent form of polymorphic
VT particularly occurring in young patients with a
structurally normal heart.
• It is usually triggered by exercise and associated
with genetic origin.

14. Pre-excited Atrial Fibrillation and
Atrial fibrillation with aberrant
conduction
• During atrial fibrillation (AF), the chaotic atrial
activation results in multiple impulses bombarding
the atrioventricular conduction system. Normally, the
atrioventricular node forms part of this conduction
system and its electrophysiological properties
ensure that the ventricular rate remains controlled.
In patients with an accessory pathway that conducts
in the antegrade direction, this safeguard is lost and,
especially when the pathway has a short refractory
period, rapid conduction to the ventricle can result.

16. Atrial Flutter With Aberrant
Conduction

17. Ventricular Fibrillation
• It is a very fast and irregular rhythm which does not
generate effective mechanical activity [>300bpm]
• It is usually triggered by a PVC and maintained as
result of repetitive micro re-entries[Similar to AF]
• ECG shows very high heart rate 300-500 beats per
min
• QRS complexes can be variable morphology and
height where QRS and ST-T are indistinguishable

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