Ventricular tachycardias are defined as 3 or more consecutive QRS complexes originating from the ventricles at a rate over 100 beats per minute. They can arise via reentry, automaticity, or triggered mechanisms. Sustained ventricular tachycardias last over 30 seconds, while non-sustained last less than 30 seconds. Wide complex tachycardias need to be differentiated between ventricular tachycardia and supraventricular tachycardia with aberrancy or preexcitation. Management involves determining the rate, origin, and cause of the ventricular tachycardia and using cardioversion, antiarrhythmic drugs like amiodarone, or ablation as appropriate.

1. VENTRICULAR TACHYCARDIAS
Shirjeel Murtaza

2. V. TACHYCARDIA
• 3 or More consecutive QRS complexes of ventricular
origin at a rate of > 100 beats / min
• VTs arise distal to bifurcation of HIS bundle
• THREE MECHANISMs
– RE-ERNTRY (90 % VT with IHD)
– AUTOMATICITY ( escape rhythms, idiopathic VTs )
– TRIGGERED ( digitalis , catecholaminergic )

3. Some TERMS
• Sustained
– For More than 30 seconds
• Non Sustained
– For Less than 30 seconds
• Frequent PVCs
– > 5 / minute
– > 30 / hour
• Occasional PVCs

4. NOW WHAT TO DO ?

5. Wide Complex Tachycardias
• Any WCT in a patient with IHD is VT
• If you don’t know the reason, its VT
• Horizontal entry of patient in ER, is VT

6. Wide Complex Tachycardias
• Regular
– VT
– Abberant ventricular conduction
– Preexisting LBBB or RBBB
– Preexisting Nonspecific Intra ventricular conduction defects
– Anterograde conduction with pre excitation ( WPW with antedromic AVRT )
– Anterograde conduction over atriofascicular or nodo ventricular connection
• Irregular
– A Fib with abberant conduction/ BBB/ IVCD
– A fib with venricular pre excitation
– Polymorphic VT ( catecholaminergic )
– Torsade de Pointes

7. Differentiating points
VT
History of MI
AV dissociation ( Pathognomic )
Capture beats
Fusion beats
Extreme Axis
Very Broad complexes ( > 140 ms )
No response to Vagal manouvers or adenosine

8. Fusion beat• Marriot et al Criteria
1. Contour and Duration of QRS are intermediate
2. PR of Fusion < PR of supraventricular complex
3. PS (PJ) of Fusion > PR of supraventricular complex
4. Vector of Fusion complex is always different from
supraventricular
• EXCEPTIONs
– BBB/ IVCD/ SVT with variable Av conduction times

9. Capture beat
• Normal Contour
• Slightly pre mature

11. How to Assess a WCT
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

12. BRUGADA (1991)
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
SVT WITH ABBERANCY
RS100PM
Brugada’s sign

13. V1,2,6 Based Criteria
used by BRUGADA
• Wellens Criteria for VT-RBBB (1978)
– V1
• Monophasic R
• Biphasic qR, QR, RS
– V6
• rS , QS , qR
• Kindwall Criteria for VT-LBBB(1988)
– V1 & V2
• R > 30ms
– V1 & V2 Start of q to nadir of s > 60ms
– Notch on Downslop of S in V1 / V2
– Any Q in V6
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

14. V1,2,6 Based Criteria
used by BRUGADA
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
LBBB
• Delayed onset of intrinsicoid deflection in leads I, V5, V6
• Broad monophasic R waves in leads I, V5, V6 that are
usually notched or slurred
• rS or QS complex in right precordial leads
RBBB
• rsR’ or rSR
• Delayed onset of intrinsicoid deflection (beginning
of QRS to peak of R wave > 0.05 seconds) in V1
and V2
• Wide slurred S wave in leads I, V5, and V6

15. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
QRSP

16. Vereckei et al
aVR40nv

17. Wide Complex Tachycardias
• Any WCT in a patient with IHD is VT
• If you don’t know the reason, its VT
• Horizontal entry of patient in ER, is VT

18. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
STEP 1
STEP 2
Tip shows the origin

19. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

20. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

21. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

22. Special VT types

23. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT
Lead iii ulti

24. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

25. • General Management
– Unstable
• DCC
– Synchronous for VT with pulse; Asynchronus for pulseless VT
– Stable
• Medical initiallly
• Search reversible cause and correct
– Ischemia
– Electrolyte imbalance
– Bradycardia
– Hypotension
– drugs
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

26. • Acute medical therapy
– Amiodarone ( agent of choice )
– Lidocaine ( ischemic origin )
– Procainamide
– B blockers ( for ACS, idiopathic RVOT )
– Calcium channel blockers ( RVOT, fascicular and digitalis )
– MgSO4 ( Torsade de pointes )
– Sodium Bicarbonate ( Acidosis ; TCA )
• RFA ( Curative for 90% of idiopathic VT )
• Surgical ablation ( for scar VT; with aneurysmectomy )
• ATP ( anti tachycardia pacing )
• Alcohol injection in coronary branch for the area
• Prevention
– B blockers ( primary )
– ICD ( primary and secondary )
• Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

27. Amiodarone
• Intravenous infusion
– Initial 5 mg/ kg over 20-120 minutes with ecg
monitoring; subsequent infusion given if necessary
according to response upto max. 1.2 g in 24 hours
• Pulseless VT or V fib. ( ACLS )
– Pre filled syringe or 300 mg diluted in 20 ml glucose 5
% after adrenaline if refractory to defibrillation.
Additional dose of 150 mg can be given by IV injection
if nececcary followed by infusion of 900 mg over 24
hours
Reference; BNF 67

28. Amiodaroone
• 5mg / kg bolus = 300 mg for 60 kg person
• INFUSION
– 1 mg / min for 6 hours
– ½ mg /min for 18 hours
24 hours
2 injections ( 300 mg ) in 100 ml burrette at 20 microdrops / min for 6 hours
then
At 10 microdrops for 18 hours

29. Amiodarone
• Oral
– Start: LOAD 800-1600mg PO qd x 1-3 wk until
response
• (for loading dose more than 1000mg / day divided w/
meals bid – tid)
– Maintenence
• 200-600 mg PO qd
• Divided bid-tid if GI intolerence

30. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

31. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT

32. • Rate
• QRS duration
• Differentiate from SVT with Abberancy
• Differentiate from pre-exicitation
• Focus of VT
• Cause of VT
• Manage VT