This document discusses criteria for differentiating between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) using electrocardiograms (ECGs) of patients presenting with wide complex tachycardia. It outlines definitions of VT and SVT, as well as diagnostic criteria including Brugada criteria, the lead aVR algorithm, and the RWPT (R wave to peak time) criterion. The document then analyzes ECGs of two case studies, concluding that the first is VT and the second is SVT with aberrant conduction based on application of the discussed criteria. It recognizes Prevost and Batelli for inventing defibrillation in 1899 by discovering electric shocks could

1. WIDE COMPLEX
TACHYCARDIA
VT VS SVT
Presented by
Dr Neeraj Nirala
GUIDE
Dr Neera Samar
UNIT HEAD
Dr R.L. Meena

2. CASE 1
 50 yr old male, labourer, smoker with H/O OF MI
5yr back admitted in ICCU with c/o of palpitation,
feeling of uneasiness for duration of 4-6 hrs.
no h/o chest pain, dyspnoea, syncope
 o/e-conscious,
oriented
no pallor, cyanosis, clubbing, edema
JVP raised.
BP- 80/60 mm hg

3. ECG AT TIME OF ADMISSION (BEFORE DC)

4. ECG AT TIME OF ADMISSION

5. ECG -AFTER DC CARDIOVERSION (200J)

7. DIFFERENTIAL DIAGNOSIS
 Ventricular tachycardia
 Supra ventricular tachycardia with abberant
conduction due to right or left BBB

8. DISCUSSION –WIDE COMPLEX TACHYCARDIAS
 Definition
 Ecg features
 Diagnostic criteria
- Brugada criteria
- Lead aVR algorithm
- Ultrasimple Brugada criterion:
RW to peak Time (RWPT)

9. DEFINITION
Wide QRS complex tachycardia is a rhythm with a rate of more than
100 b/m and QRS duration of more than 120 ms
VT (80%)
SVT (20%)

10.  VT- Non-sustained VT: three or more ventricular beats with a
maximal duration of 30 seconds.
 Sustained VT: a VT of more than 30 seconds duration (or less if
treated by electrocardioversion within 30 seconds).
 Monomorphic VT: all ventricular beats have the same
configuration.
 Polymorphic VT: the ventricular beats have a changing
configuration. The RR interval is 180-600 ms
 Biphasic VT: a ventricular tachycardia with a QRS complex
that alternates from beat to beat.
 SVT- a tachycardia dependent on participation of structure at
or above bundle of His
 LBBB morphology- QRS > 12 msec. with prominent negative
deflection in V1
 RBBB morphology- QRS > 12 msec. with prominent positive
deflection in V1.

11. PHYSICAL EXAMINATION
 Signs of AV dissociation favours VT
- cannon waves
- varying intensity of S1
- variation of systolic BP
- hypotension
 Termination of WCT with maneuvers ~
carotid,vasalva,adenosine favours SVT

12. BRUGADA CRITERIA

13. STEP 1- RS COMPLEX IN PRECORDIAL LEADS

14. STEP 2- R TO NADIR OF S (BRUGADA SIGN)

15. STEP 3- A-V DISSOCIATION

16. STEP.4- QRS MORPHOLOGY

17. OTHER ECG FINDINGS FAVOUR VT
 North - west QRS axis deviation i.e superior and rightward
minus 90 degree to 180 degree
 Negative or positive concordance of QRS complex in all
precordial leads
 AV dissociaton : Fusion beats, capture beats
 In LBBB, QRS duration >160 ms
 In RBBB,QRS duration > 140 ms
 Previous ECG show MI

18. RABBIT EAR IN RBBB PATTERN

19. CONCORDANCE & NORTH WEST AXIS

20. POSITIVE CONCORDANCE

21. FUSION & CAPTURE BEATS
A fusion beat is descriptive term for the merging of an ectopic beat and a capture
beat.
When an ectopic rhythm is present, as in ventricular tachycardia, the ectopic foci
may conduct in a retrograde direction. If the ventricles are not refractory, this
leads to a conducted P wave that causes a normal QRS to follow. This is a
capture beat. However, when the ectopic focus fires at the same time that the P
wave reaches the ventricles, the QRS is a "combination" of the capture and
ectopic morphology.
So, ECG strip shows series of ectopic beats (a run of Vtach; the ectopic rhythm)
followed by capture beats (normal configuration; the sinus rhythm) and then a
gradual merging of the capture beats into the ectopic beats.

22. AVR ALGORITHM

23. If the distance traveled on the Y axis in the initial
40ms of the QRS complex is smaller than that
traveled in the terminal 40ms of the QRS complex, a
VT is much more likely

24. ULTRASIMPLE BRUGADA CRITERION: RW TO PEAK
TIME (RWPT)
 In 2010 Joseph Brugada et al. published a new
criterion to differentiate VT from SVT in wide
complex tachycardias: the R wave peak time in
Lead II [4].
 They suggest measuring the duration of onset of
the QRS to the first change in polarity (either nadir
Q or peak R) in lead II. If the RWPT is ≥ 50ms the
likelihood of a VT very high (positive likelihood ratio
34.8).

26. ECG DISCUSSION
 Rate : 180 ventricular rate
 Rhtdym : regular
 Axis : normal
 P wave not clearly discernable
 QRS COMPLEX: Slurred wide complex of duration
200msec
 QS PATTERN in V1 to V4
 BRUGADA’s criteria
 Step 1: RS complex inV4 lead
 Step 2 : RS duration is 120msec
 All these favours VT

27.  AVR ALGORITM
 Step 1: intial r wave : absent
 Step 2: r wave is 50 msec
 This favours VT
 Ultrasimple Brugada criterion: RW to peak Time
(RWPT)
 Here RWPT IS 60msec
 This favors VT

28. OUR ECG
Favours VT •Against VT
 h/o MI
 V4 RS complex
duration RS >100 ms
 A-v dissociation
 Avr s/o vt
 RWPT > 50ms
 Axis is normal
 Not typical vt LBB
morphology
 Qrs duration .14 s with
lbbb
 Non concordance
 Presence of RS complex

29. CONCLUSION-DIAGNOSIS
 VENTRICULAR TACHYCARDIA WITH LBBB
MORPHOLOGY
 CAD- OLD ANT.SEPTAL MI

30. CASE 2
 A 26yrs old man presented to emergency with
complaints of feeling of uneasiness , heaviness in
chest, dyspnoea with no significant past history of
any medical illness
 O/E
 BP 80/60
 No P/CY/CL/ICT/LAP/EDEMA

33. DISCUSSION
Rate : 210 ventricular rate
Rhythm : not sinus
P wave cant be discernable
QRS COMPLEX : Wide ; duration is nearly 160 msec
Concordance: NO
Fusion beats and AV dissociation : NO
Applying Brugada algorithm
Step 1: rS complex present
Step 2: rS complex duration: here 80msec
Step 3: av dissociation here absent
Step 4 : morphological criteria
RBBB pattern is present
In V1 : rSR pattern
In V6 : height of S > R so R/S > 1
All these finding favours that it is SVT with abberancy

34. AVR algorithm
Intial R wave in AVR : NO
Wave r = 40 msec
No notching in decending limb and no negative predominace of QRS
Vi < Vt
All these favours SVT with abberancy
Ultrasimple Brugada criterion: RW to peak Time (RWPT)
HERE RWPT is 40msec in Lead II
So it is favours SVT with abberancy

35. DISCOVERY OF DEFIBRILLATOR
PREVOST BATELLI
THANK YOU
Defibrillation was invented in 1899 by Prevost and Batelli,
Two physiologists from University of Geneva, Switzerland. They discovered
that small electric shocks could induce ventricular fibrillation in dogs, and that
larger charges would reverse the condition.