This document summarizes an ECG of a 55-year-old male patient presenting with palpitations. The initial ECG shows a wide complex tachycardia. Differential diagnoses include ventricular tachycardia or supraventricular tachycardia with aberrancy. ECG features favoring ventricular tachycardia over supraventricular tachycardia are discussed, including Brugada criteria and the lead AVR algorithm. Analysis of the patient's ECG determines the rhythm is ventricular tachycardia with left bundle branch block morphology based on his history of myocardial infarction.

1. ECG OF THE MONTH
CANDIDATE : DR.SARATH MENON.R
DEPT. OF CARDIOLOGY
M G M MEDICAL COLLEGE,INDORE

2.  55 yr old male, labourer,c/c smoker from Jabua
admitted in ICCU on 8.01.2011 with c/o of
palpitation, gabrahaat for duration of 4-6 hrs.
no h/o chest pain,dyspnoea,syncope
 o/e-
conscious,oriented
no pallor,cyanosis,clubbing,edema
JVP raised.
pulse- rapid ~ 170/mt regular
BP- systole 80/60

3.  S1- variable. S2- normal
 Chest – b/l clear ,no added sounds
 P/A- soft,non-tender
liver,spleen –non palpable
 Past history
- h/o similar episodes before
- h/o MI – 5 yr back

4. ECG AT TIME OF ADMISSION (BEFORE DC)

5. ECG AT TIME OF ADMISSION

6. ECG -AFTER DC CARDIOVERSION (200J)

8. DIFFERENTIAL DIAGNOSIS
 Ventricular tachycardia
 Supra ventricular tachycardia with abberancy

9. DISCUSSION –WIDE COMPLEX TACHYCARDIAS
 Definition
 Ecg features
 Diagnostic criteria
- Brugada criteria
- Lead aVR algorithm

10. 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
SVT (20%)
VT (80%)
Stewart RB. Ann Intern Med 1986

11.  VT- 3 or more consecutive ventricular premature
beats with a rate of 100/mt or more
 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.

12. DIFFERENTIAL DIAGNOSIS
 Ventricular tachycardia ( 80 %)
 SVT with abberant conduction (20%)
- SVT with BBB abberancy (fixed or functional)
- pre-excited SVT (anomalous AV connection)

13. SVT VS VT
CLINICAL HISTORY
Age - ≥ 35 ys → VT
Underlying heart disease Previous MI → 98% VT
Pacemakers Increased risk of ventricular tachyarrhythmia

14. 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

15. ECG
 Rate
 Regularity

16. BRUGADA CRITERIA

17. STEP 1- RS COMPLEX IN PRECORDIAL LEADS

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

19. STEP 3- A-V DISSOCIATION

20. STEP.4- QRS MORPHOLOGY

21. VT WITH LBBB MORPHOLOGY

22. SVT WITH LBBB MORPHOLOGY

23. STEP 4- VT WITH RBBB MORPHOLOGY

25. SVT WITH RBBB MORPHOLOGY

26. OTHER ECG FINDINGS FAVOUR VT
 North - west QRS axis deviation
 Negative or positive concordance
 Fusion beats, capture beats
 Ventriculoatrial conduction with block
 Axis shift of > 40° from SR
 RBBB morphology with LAD > - 30°
 LBBB morphology with RAD > + 90 °
 In LBBB, QRS duration >160 ms
 In RBBB,QRS duration > 140 ms
 Previous ECG show MI or previous ECG show that during
sinus rhythm, bundle branch block is present, which changes
in configuration during tachycardia

27. RABBIT EAR

28. CONCORDANCE & NORTH WEST AXIS

29. POSITIVE CONCORDANCE

30. FUSION & CAPTURE BEATS

31. VT VERSUS AVRT

32. LEAD AVR

33. AVR ALGORITHM

34. OUR ECG
Favours VT •Against VT
 h/o MI  Axis is normal
 v4 RS complex  Not typical vt LBB
duration RS >100 ms morphology
 A-v dissociation  Qrs duration .14 s with
 Avr s/o vt lbbb
 Initial axis shift > 40°  Non concordance
 Presence of RS complex

35. CONCLUSION-DIAGNOSIS
 VENTRICULAR TACHYCARDIA WITH LBBB
MORPHOLOGY
 CAD- OLD ANT.SEPTAL MI
 QT PROLONGED

36. SUMMARY

38. THANK U….