The potential and limitations of standard electrocardiography for the differential diagnosis of wide QRS complex tachycardias

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Abstract

The possibility to identify potentially life-threatening ventricular arrhythmias by analysis of standard electrocardiography (ECG) parameters without the use of sophisticated and expensive diagnostic techniques, such as electrophysiological heart studies, has been an important achievement of the last decades. Current differential diagnostic methods for wide QRS complex tachycardias can be categorized into 4 groups: 1) identification the ECG signs diagnostic of ventricular tachycardia, such as atrioventricular dissociation and/or sinus captures and/or fusion QRS complexes; 2) analysis of the distinct morphological features of QRS complexes during wide QRS complex tachycardias; 3) analysis of the ECG characteristics in between wide QRS complex tachycardia attacks; 4) comparison of the morphological QRS features during wide QRS complex tachycardia and during sinus rhythm periods. The list of ECG algorithms for differential diagnosis of wide QRS complex tachycardias has been growing and updated year after year; however, all of them have their limitations. Most frequently, the differential diagnosis between ventricular and aberrant supraventricular tachycardias is based on the morphological criteria of wide QRS complexes developed by H.J. Wellens et al., P. Brugada et al., M. Griffith et al., K.E. Kindwal et al., A. Vereckei et al. At the same time, there is a continuous search for new algorithms or criteria that could be easily used without decreased specificity and/or sensitivity of the diagnosis of ventricular tachycardia. The aim of this review is to comprehensively analyze the literature data and results of our own studies on the potential and limitation of standard ECG for the differential diagnosis of ventricular and various aberrant supraventricular tachycardias.

About the authors

H. F. Salami

National Medical Research Cardiology Center

Author for correspondence.
Email: hussein_salami@mail.ru
ORCID iD: 0000-0001-9751-7767

Hussein F. Salami – Postgraduate Student, Department of Clinical Electrophysiology and X-Ray Methods of Treatment of Cardiac Arrhythmias.

15A 3-ya Cherepkovskaya ul., Moscow, 121552

Россия

N. B. Shlevkov

National Medical Research Cardiology Center

Email: nik.shlevkov@inbox.ru
ORCID iD: 0000-0003-3956-1860

Nicolay B. Shlevkov – MD, PhD, Senior Research Fellow, Laboratory of Interventional Methods for Diagnostics and Treatment of Cardiac Rhythm and Conduction Disorders and Syncopal Conditions, Department of Clinical Electrophysiology and X-Ray Methods of Treatment of Cardiac Arrhythmias/

15A 3-ya Cherepkovskaya ul., Moscow, 121552

Россия

S. F. Sokolov

National Medical Research Cardiology Center

Email: sokolov@astrocard-meditek.ru
ORCID iD: 0000-0002-3176-8229

Sergey F. Sokolov – MD, PhD, Leading Research Fellow, Department of Clinical Electrophysiology and X-Ray Methods of Treatment of Cardiac Arrhythmias/

15A 3-ya Cherepkovskaya ul., Moscow, 121552

Россия

References

  1. Coumel P, Leclercq JF, Attuel P, Maisonblanche P. The QRS morphology in post-myocardial infarction ventricular tachycardia. A study of 100 tracings compared with 70 cases of idiopathic ventricular tachycardia. Eur Heart J. 1984;5(10):792–805. doi: 10.1093/oxfordjournals.eurheartj.a061568.
  2. Marriott HJL, Sandler IA. Criteria, old and new, for differentiating between ectopic ventricular beats and aberrant ventricular conduction in the presence of atrial fibrillation. Prog Cardiovasc Dis. 1966;9:18–28.
  3. Bazan V, Bala R, Garcia FC, Sussman JS, Gerstenfeld EP, Dixit S, Callans DJ, Zado E, Marchlinski FE. Twelve-lead ECG features to identify ventricular tachycardia arising from the epicardial right ventricle. Heart Rhythm. 2006;3(10): 1132–9. doi: 10.1016/j.hrthm.2006.06.024.
  4. Bazan V, Gerstenfeld EP, Garcia FC, Bala R, Rivas N, Dixit S, Zado E, Callans DJ, Marchlinski FE. Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction. Heart Rhythm. 2007;4(11):1403–10. doi: 10.1016/j.hrthm.2007.07.004.
  5. Buxton AE, Marchlinski FE, Doherty JU, Flores B, Josephson ME. Hazards of intravenous verapamil for sustained ventricular tachycardia. Am J Cardiol. 1987;59(12):1107–10. doi: 10.1016/0002-9149(87)90857-5.
  6. Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Am J Cardiol. 1988;61(15):1279–83. doi: 10.1016/00029149(88)91169-1.
  7. Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649–59. doi: 10.1161/01.cir.83.5.1649.
  8. Wellens HJ, Brugada P. Diagnosis of ventricular tachycardia from the 12-lead electrocardiogram. Cardiol Clin. 1987;5(3):511–25.
  9. Wellens HJ. Electrophysiology: ventricular tachycardia: diagnosis of broad QRS сomplex tachycardia. Heart. 2001;86:579–85.
  10. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J. 2007;28(5):589–600. doi: 10.1093/eurheartj/ehl473.
  11. Datino T, Almendral J, Avila P, González-Torrecilla E, Atienza F, Arenal A, Fernández-Avilés F. Specificity of electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardia in patients with intraventricular conduction defect. Heart Rhythm. 2013;10(9): 1393–401. doi: 10.1016/j.hrthm.2013.07.006.
  12. Oreto G, Luzza F, Satullo G, Donato A, Carbone V, Calabrò MP. Wide QRS complex tachycardia: an old and new problem. G Ital Cardiol (Rome). 2009;10(9):580–95.
  13. Jastrzebski M, Sasaki K, Kukla P, Fijorek K, Stec S, Czarnecka D. The ventricular tachycardia score: a novel approach to electrocardiographic diagnosis of ventricular tachycardia. Europace. 2016;18(4):578–84. doi: 10.1093/europace/euv118.
  14. Drew BJ, Scheinman MM. ECG criteria to distinguish between aberrantly conducted supraventricular tachycardia and ventricular tachycardia: practical aspects for the immediate care setting. Pacing Clin Electrophysiol. 1995;18(12 Pt 1):2194–208.
  15. Griffith MJ, de Belder MA, Linker NJ, Ward DE, Camm AJ. Multivariate analysis to simplify the differential diagnosis of broad complex tachycardia. Br Heart J. 1991;66(2):166–74. doi: 10.1136/hrt.66.2.166.
  16. Griffith MJ, de Belder MA, Linker NJ, Ward DE, Camm AJ. Difficulties in the use of electrocardiographic criteria for the differential diagnosis of left bundle branch block pattern tachycardia in patients with a structurally normal heart. Eur Heart J. 1992;13(4):478–83. doi: 10.1093/oxfordjournals.eurheartj.a060200.
  17. Sousa PA, Pereira S, Candeias R, de Jesus I. The value of electrocardiography for differential diagnosis in wide QRS complex tachycardia. Rev Port Cardiol. 2014;33(3):165–73. doi: 10.1016/j.repc.2013.07.016.
  18. Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017;52(4):484–92. doi: 10.1016/j.jemermed.2016.09.010.
  19. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89–98. doi: 10.1016/j.hrthm.2007.09.020.
  20. Josephson MB, Zimetbaum P. The tachyarrhythmias. In: Kasper DL, Brauwald K, Fauci A, Hauser S, Longo D, Jameson JL, editors. Harrison's Principle of Internal Medicine. 16th edition. New York: McGraw-Hill Professional; 2004. 2607 p.
  21. Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, Deal BJ, Dickfeld T, Field ME, Fonarow GC, Gillis AM, Granger CB, Hammill SC, Hlatky MA, Joglar JA, Kay GN, Matlock DD, Myerburg RJ, Page RL. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;72(14):1677–749. doi: 10.1016/j.jacc.2017.10.053.
  22. Задионченко ВС, Шехян ГГ, Щикота АМ, Ялымов АА. Дифференциальная диагностика «широких» тахикардий. Русский медицинский журнал. 2012;(14):734.
  23. Garratt C, Antoniou A, Ward D, Camm AJ. Misuse of verapamil in pre-excited atrial fibrillation. Lancet. 1989;1(8634):367–9. doi: 10.1016/s0140-6736(89)91734-0.
  24. Gulamhusein S, Ko P, Klein GJ. Ventricular fibrillation following verapamil in the Wolff-Parkinson-White syndrome. Am Heart J. 1983;106(1 Pt 1):145–7. doi: 10.1016/00028703(83)90452-0.
  25. Tchou PJ, Jazayeri M, Avitall B. Wide QRS tachycardias: Mechanisms differential diagnosis and acute management. In: Naccarelli GV, editor. Cardiac arrhythmias: A practical approach. Mount Kisco: Futura Publishing; 1991. p. 217– 41.
  26. Казаков СА, Рачок СМ, Руцкая ТА, Чечко РЮ, Курсевич ВВ, Самоходкина СВ, Бабак ГА, Шумилов ВН. Дифференциальная диагностика тахикардий с широким комплексом QRS. Часть 1. Традиционные и новые критерии дифференциальной диагностики желудочковых и суправентрикулярных тахикардий. Здравоохранение (Минск). 2016;(1):56–9.
  27. Eckardt L, Deneke T. Updated ESC guideline: innovations for the treatment of ventricular arrhythmias and recommendations for prevention of sudden cardiac death. Herzschrittmacherther Elektrophysiol. 2016;27(3):288–94. doi: 10.1007/s00399-016-0446-2.
  28. Лебедев ДС. Тахикардии с широкими комплексами QRS (дифференциальный диагноз, лечебная тактика). Вестник аритмологии, 1998;(7):65–73.
  29. Wang PJ, Friedman PL. "Clockwise" and "counterclockwise" bundle branch reentry as a mechanism for sustained ventricular tachycardia masquerading as supraventricular tachycardia. Pacing Clin Electrophysiol. 1989;12(8): 1426–32. doi: 10.1111/j.1540-8159.1989.tb05058.x.
  30. Салами ХФ, Шлевков НБ, Новиков ПС, Миронов НЮ, Певзнер АВ. Новые электрокардиографические критерии для дифференциальной диагностики тахикардий с расширенными комплексами QRS по типу блокады левой ножки пучка Гиса. Сибирский медицинский журнал. 2019;34(1): 98–106. doi: 10.29001/2073-8552-2019-34-198-106.
  31. Шлевков НБ, Салами ХФ, Киктев ВГ, Соколов СФ. Новые ЭКГ-критерии дифференциальной диагностики тахикардий с «широкими» комплексами QRS по типу блокады правой ножки пучка Гиса. Терапевтический архив. 2019;91(4):83–9. doi: 10.26442/00403660.2019.04.000210.

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Copyright (c) 2019 Salami H.F., Shlevkov N.B., Sokolov S.F.

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