Wide Complex Tachycardia

Place the patient on continuous monitoring and obtain a 12-lead ECG as soon as feasible, but do not delay electrical treatment for a prolonged diagnostic exercise when the patient is unstable. Acute tachyarrhythmia management begins with hemodynamic assessment, and prompt restoration of sinus rhythm by direct-current cardioversion is required when instability is present. Wiley+1WileyJCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac ...PubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Use a rhythm-first branch point. A regular monomorphic wide complex tachycardia has a differential dominated by ventricular tachycardia (VT), supraventricular tachycardia (SVT) with aberrant intraventricular conduction, and antidromic atrioventricular reentrant tachycardia. An irregular wide complex tachycardia instead raises pre-excited atrial fibrillation (AF), polymorphic VT, or an atrial arrhythmia with variable aberrancy. ScienceDirect+3ScienceDirectManagement strategies in wide QRS complex tachycardia - ScienceDirectScienceDirectWide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supraventricular tachycardia with aberrant conduction - ScienceDirectWileyJCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac ...PubMedDifferential Diagnosis of Wide QRS Tachycardias

Do not allow apparent clinical stability to be interpreted as proof of SVT. VT is the most frequent regular wide complex tachycardia, and misclassification of VT as SVT can lead to potentially lethal treatment choices. ScienceDirect+2ScienceDirectManagement strategies in wide QRS complex tachycardia - ScienceDirectScienceDirectWide QRS complex tachycardia: ECG differential diagnosis - ScienceDirectScienceDirectBest Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia

Acquire a 12-lead ECG during tachycardia and compare it with a prior baseline tracing whenever available. A systematic assessment integrates clinical history, comparison with the resting ECG, pathognomonic VT features, and morphology in precordial leads and aVR; no isolated algorithm should substitute for this sequence. Wiley+2WileyAre Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department? - Martín‐Sánchez - 2014 - Academic Emergency Medicine - Wiley Online LibraryPubMedCurrent algorithms for the diagnosis of wide QRS complex tachycardias - PubMedPubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Identify atrioventricular dissociation whenever possible. Regular P waves that are dissociated from QRS complexes, a ventricular rate exceeding the atrial rate, capture beats, and fusion beats are diagnostic clues favoring VT. A history of acute myocardial infarction together with wide complex tachycardia also supports VT. PubMed+1PubMedDiagnosis and management of ventricular tachycardiaPubMedIII SBC Guidelines on the Analysis and Issuance of Electrocardiographic Reports - Executive Summary

If definitive findings are absent, use a reproducible algorithm such as Brugada, Vereckei-aVR, or lead II R-wave peak time criteria, recognizing that diagnostic performance is lower in real-world interpretation than in original reports. In a meta-analysis of 14 studies including 3,966 patients with regular WCT, Brugada, Vereckei-aVR, and lead II R-wave peak time were among the assessable ECG algorithms. BMJ+1BMJDiagnostic accuracy of different ECG-based algorithms in wide QRS complex tachycardia: a systematic review and meta-analysisWileyAre Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department? - Martín‐Sánchez - 2014 - Academic Emergency Medicine - Wiley Online Library

In a stable regular monomorphic WCT, obtain the diagnostic ECG before treatment if this does not compromise the patient, establish IV access and continuous monitoring, and proceed as presumed VT when the mechanism remains uncertain. Historical guideline recommendations support IV procainamide and/or sotalol for pharmacologic termination of stable WCT, although those recommendations were based on small randomized studies. Oxford AcademicOxford AcademicACC/AHA/ESC guidelines for the management of patients with ...

Adenosine can be considered for stable, regular WCT as a diagnostic and potentially therapeutic maneuver. Advanced cardiovascular life support guidance cited in the literature describes adenosine as safe and potentially effective in the initial management of stable regular WCT; termination supports a reentrant SVT mechanism, whereas transient AV nodal block can expose ongoing atrial activity. JAMA+1JAMAAdenosine Conversion of Wide Complex Tachycardia - JAMA NetworkJAMAWide Complex Tachycardia and Adenosine - JAMA Network

Do not use adenosine response as a universal mechanism test. Adenosine may clarify atrial tachycardia conducted with bundle-branch block, but ECG interpretation, baseline comparison, and VT criteria remain necessary because a stable WCT can still be VT. JAMA+2JAMAWide Complex Tachycardia and Adenosine - JAMA NetworkWileyAre Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department? - Martín‐Sánchez - 2014 - Academic Emergency Medicine - Wiley Online LibraryPubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Pre-excited AF is suggested by an irregular wide complex tachycardia with changing QRS morphology and a rapid ventricular rate. Variable ventricular fusion through the AV node and one or more accessory pathways accounts for changing QRS width and delta-wave appearance. Because AV-nodal suppression can favor accessory-pathway conduction, avoid AV-nodal-suppressing drugs when this pattern is possible. Wiley+1WileyJCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac ...PubMedDifferential Diagnosis of Wide QRS Tachycardias

Expand the differential when the ECG or context is atypical. WCT can arise from ventricular pacing-associated tachycardias, ventricular pre-excitation, preexisting or rate-related bundle-branch block, and sodium-channel-blocker toxicity. Toxicity-associated ECG patterns include sinus tachycardia with QRS duration greater than 100 ms, right-axis deviation of 130° to 270°, and/or R-wave changes in aVR. jacc+1jaccAn Extreme Wide-Complex Tachycardia and TremorsScienceDirectWide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supraventricular tachycardia with aberrant conduction - ScienceDirect

Ask specifically about structural heart disease, prior myocardial infarction, implanted devices, prior baseline bundle-branch block, known Wolff-Parkinson-White pattern, and medication or overdose exposure. These data direct ECG interpretation and determine whether the initial endpoint is cardioversion, VT suppression, accessory-pathway management, device evaluation, or toxicology-directed resuscitation. ScienceDirect+3ScienceDirectWide-complex tachycardia: beyond the traditional differential diagnosis of ventricular tachycardia vs supraventricular tachycardia with aberrant conduction - ScienceDirectWileyAre Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department? - Martín‐Sánchez - 2014 - Academic Emergency Medicine - Wiley Online LibraryPubMedDiagnosis and management of ventricular tachycardiaPubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

After termination or cardioversion, retain pre-treatment ECGs and obtain a baseline 12-lead ECG for comparison. A resting tracing may reveal baseline conduction disease, prior infarct pattern, or evidence of pre-excitation and is central to distinguishing VT from SVT with aberrancy in recurrent events. Wiley+2WileyAre Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department? - Martín‐Sánchez - 2014 - Academic Emergency Medicine - Wiley Online LibraryPubMedDiagnosis and management of ventricular tachycardiaPubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Evaluate for structural substrate with echocardiography when VT is suspected or when clinical history suggests structural disease. In the structured WCT approach, laboratory tests and echocardiography are part of post-stabilization assessment, and prior infarction or structural abnormalities increase the importance of assigning the rhythm as VT rather than benign SVT. PubMed+1PubMedDiagnosis and management of ventricular tachycardiaPubMedManagement of hemodynamically stable wide QRS complex tachycardia in patients with implantable cardioverter defibrillators

Refer recurrent sustained monomorphic VT, suspected accessory-pathway-mediated WCT, or diagnostically unresolved WCT for electrophysiology evaluation. Catheter ablation can be definitive for reentrant SVT, with guideline-cited success of at least 90% for patients whose episodes require acute management; typical atrial flutter ablation has reported success above 90% through up to 2 years of follow-up. BMJ+1BMJManagement of cardiac conduction abnormalities and arrhythmia in ...WileyJCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac ...