Wide QRS tachycardia is a rhythm with a rate

of more than 100 beats/min and having a

QRS duration of > 120milliseconds (ms).

Any deviation in the normal pathway of
ventricular activation may cause
widening of the QRS complex.
Different pharmacologic management
For possible ablation
Prognostication
Supraventricular tachycardia (SVT) with
aberrant conduction
Pre-excited tachycardia
Ventricular tachycardia (VT)
Pacemaker-mediated tachycardia

Conduction over the His-Purkinje system is
blocked in either the right or the left bundle
or the distal Purkinje system (intraventricular
conduction delay).

obtain a previous ECG if available
important clues to differentiate VT vs SVT
- AV dissociation
- fusion or capture beats
- QRS width
- QRS axis
- QRS regularity
- QRS concordance
- QRS morphology
independent atrial and ventricular activation
50% of patients with VT
rare in SVT
best seen in leads V
1
and inferior leads
Lewis lead amplifies P waves
dissociated P wave totally (capture) or
partially (fusion) activates the ventricle in
advance of the next VT cycle
premature narrow QRS complex during VT
highly specific for VT

consider VT if:
-RBBB pattern > 140 ms
-LBBB pattern > 160 ms
normal axis favors SVT
left or right axis deviation favors VT
extreme left or right axis deviation
(northwest) axis strongly favors VT
slight irregularity in the R - R interval may be seen
in SVT and VT
marked irregularity of R - R interval suggests atrial
fibrillation conducted via accessory pathway
strongly favors VT
positive concordance (positive QRS
in V
1
to V
6
) suggests posterobasal
origin
negative concordance (negative
QRS in V
1
to V
6
) suggests
anteroapical origin
Negative
Concordance
Positive Concordance
V
1
and V
6
most useful
typical RBBB or LBBB pattern more likely
to be SV
atypical pattern is more likely to be VT
abrupt change from one QRS morphology
to another during regular tachycardia
suggests VT
QRS morphology during tachycardia
similar to isolated PVC during sinus
rhythm suggests VT
RBBB morphology QRS
- triphasic pattern with rsR` or rR` in V
1

- qRs in V
6
LBBB morphology QRS
- rS (r < 30 ms; rapid downslope of S) or QS in V
1
- monophasic R in V
6
QRS Morphology Favoring VT
RBBB morphology QRS
-monophasic or biphasic in V
1
; R > R
-rS or QS in V
6

LBBB morphology QRS
-rightward axis
-broad R wave (> 40 ms); notching in the
downslope of the S wave in V
1

-qR or QS in V
1
Brugada's sign: The interval from the R wave to the bottom of the S ways = 0.10
sec---characteristic VT
Josephson's sign: a small notching near the low point of the S wave = an
indicator of VT
Favors SVT

Favors VT
RBBB
morphology
V1

Triphasic
rsR, rR
Monophasic
R>R
V6

qRs rS or QS
LBBB
morphology
V1 rS (r < 30 ms;)
or QS
broad R (> 40
ms); notching of
the S
qR or QS in V1
V6 monophasic R
if hemodynamically unstable, prompt
electrical cardioversion is indicated

if stable and tachycardia mechanism is
uncertain, therapeutic trial with:
- adenosine
- procainamide
- lidocaine
- Cardioversion

avoid verapamil unless VT has been
ruled out with certainty
When in doubt, the working
diagnosis is VT until proven
otherwise!
A. Supraventricular tachycardia
B. Ventricular Fibrillation
C. Ventricular Tachycardia
D. Atrial Fibrillation

A. Supraventricular tachycardia
B. Ventricular Fibrillation
C. Ventricular Tachycardia
D. Atrial Fibrillation with abberant
conduction