The Efficient and Smart Methods for Diagnosis of SVT 대구파티마병원순환기내과정병천

The Efficient and Smart Methods for Diagnosis of SVT 대구파티마병원순환기내과정병천

Differentiation Supraventricular Origin from Ventricular Origin on ECG. QRS-Complex Width. 1. Narrow QRS-Complex Tachycardia (<120 ms). almost always SVT, rarely VT (fascicular origin). 2. Wide QRS-Complex Tachycardia (> 120 ms). a. Ventricular Tachycardia. b. SVT with Bundle Branch Block. c. SVT with Anterograde Conduction over Accessory Pathway. Relationship and morphology on P-wave, QRS-Complex. a. Regularity. b. P-wave > QRS-complex.

Differential Diagnosis for Narrow QRS-Complex Tachycardia on ECG. Absence of P-wave. 1. Regular: AVNRT. JT 2. Irregular: Atrial Fibrillation. Presence of P-wave. 1. RP interval < PR interval (*short RP interval) AVNRT (< 70 ms) AVRT 2. RP interval > PR interval (*long RP interval) AVNRT (atypical) AVRT (slow conducting accessory pathway) AT, JT

Short RP narrow QRS tachycardia: Absence of P-wave. 1. Regular: AVNRT. JT 2. Irregular: Atrial Fibrillation.

Short RP narrow QRS tachycardia: Pseudo s-wave in II, III, avf leads. Pseudo r-wave in V1 lead. pseudo s-wave + pseudo r-wave : 2/3 only pseudo r-wave : 1/5 only pseudo s-wave : 1/10

Short RP narrow QRS tachycardia: When absence of pseudo s-wave or pseuro r-wave, II, III, avf: negative P-wave, V1: Positive P-wave : AVNRT Other patterns : AVRT AVNRT AVRT

Short RP narrow QRS tachycardia: Difference between the RP interval at limb lead (III) and at precordial lead (V1) AVNRT AVRT (right posteroseptal AP) J Am Coll Cardiol 1997;29:394 402

Short RP narrow QRS tachycardia: J Am Coll Cardiol 1997;29:394 402

Short RP narrow QRS tachycardia: Utility of the avl lead in the electrocardiographic diagnosis of atrioventricular node reentrant tachycardia SVT Sinus rhythm Europace (2009) 11, 944 948

Long RP narrow QRS tachycardia: AT: most common. II, III, avf: negative P-wave, V1: Positive P-wave : RP/PR ratio 1.65 P-wave duration 96 ms P-wave polarity AVNRT, PJRT AT Non-AT (PJRT) JournalofArrhythmia30(2014)376 381

Differential Diagnosis for Wide QRS-Complex Tachycardia on ECG. -Distinguish SVT from VT-. Ventricular Tachycardia. 1. VA disassociation (30%: QRS-complex P-wave). 2. Fusion or Capture beat. 3. QRS width (LBBB morphology > 160 ms, RBBB > 140 ms) 4. Configurational Characteristics on Leads V1, and V6 5. RS interval on precordial leads > 100 ms. 6. Concordance on precordial leads. 7. Q-wave on resting ECG, decreased LVEF Proposed Algorithms. 1. Brugada Algorithm. 2. Verekei Algorythm. 3. Other Criteria.

Differential Diagnosis for Wide QRS-Complex Tachycardia on ECG. -Distinguish SVT from VT-. Wide QRS Tachycardia on SVT 1. Aberrant Conduction. 2. Pre-existing Bundle Branch Block. 3. Intraventricular Conduction Disturbance. 4. Pre-excitation. Wide QRS Tachycardia on ECG. VT accounting for up to 80% of all cases. The history of myocardial infarction, congestive heart failure, and recent angina pectoris have a positive predictive value for VT of 98, 100, and 100%.

AV disassociation during tachycardia: 1:1, 2:1, or Wenckebach conduction occurs up to 50% of all VT. Atypical AVNRT. Mahaim fiber (nodo-fascicular/nodo-ventricular).

AV disassociation during tachycardia: 1:1, 2:1, or Wenckebach conduction occurs up to 50% of all VT. Atypical AVNRT. Mahaim fiber (nodo-fascicular/nodo-ventricular).

Fusion or Capture beat during tachycardia: AV dissociation + Fusion/Capture beat = pathognomonic finding for VT

Fusion or Capture beat during tachycardia: SVT: AP + RBBB/intermittent recovery of RBBB. Br Heart J 1991;66:166-74

RBBB or LBBB morphology during tachycardia: History: Sandler and Marriott: Concordance, good rabbit vs. bad rabbit. Swanick et al: S-wave in V4 deeper than in V1, r-wave in V1>30 ms, negative in lead I suggest VT (LBBB morphology). Wellens: proposing Classical criteria using EPS. Coumel: QR patten except avr, QS pattern on V5~6 suggest VT

The Brugada Algorythm: The starting point is whether RS pattern is present in precordial leads. RS interval and Classic criteria are applied later respectively.

The avr and Vi/Vt Vereckei Algorythm: The avr lead should always present negative vector in normal condition. Therefore the presence of R-wave in avr means VT, and the with of r- or q- wave > 40 ms also mean VT. A: the voltage during initial 40 ms (Vi) B: the voltage during terminal 40 ms (Vt) Vi/Vt ratio 1 means VT

The Griffith Proposal: 1. The history of previous MI 2. In the avf lead, a predominant negative deflection was suggestive to VT especially when Q-wave was present in RBBB pattern tachycardia. 3. In RBBB pattern tachycardia, a monophasic or biphasic waveform in V1 suggested VT, a triphasic RSR, rsr configuration suggest SVT. 4. In the avf, QS or qr waveform was suggestive to VT when LBBB pattern tachycardia. Whereas Rs complex was specific for SVT. 5. Change in axis of more than 40 degree between SR and tachycardia were independent predictor of VT. Independent P-wave activity, and PVC during sinus rhythm with the same QRS morphology as that in tachycardia increase the diagnostic accuracy. Griffith et al studied 53 patients with LBBB pattern tachycardia and found that the classical VT criteria have a sensitivity of 100% in patients with previous MI, but only 50% in patients with structurally normal hearts or non-ischemic cardiomyopathy. Unless typical BBB morphology was found in the setting of BCT, VT should be diagnosed by default.

Pre-excited SVT vs. VT: No morphological differentiation is theoretically possible. Bundle Branch and Interfascicular Reentry Tachycardia: During BBRVT, rapid intrinsicoid deflection on opposite side indicates that the later conduction occurs through the specific conduction system, whereas the slurred inintial conduction occurs through the myocardium. Fascicular Ventricular Tachycardia: Usually the RS interval in precordial leads < 80 ms because the conduction occurs through the specific conduction system.

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