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ABSTRACT: The primary goal of the initial ECG evaluation of every wide complex tachycardia is to determine whether the tach-
yarrhythmia has a ventricular or supraventricular origin. The answer to this question drives immediate patient care decisions,
ensuing clinical workup, and long-term management strategies. Thus, the importance of arriving at the correct diagnosis can-
not be understated and has naturally spurred rigorous research, which has brought forth an ever-expanding abundance of
manually applied and automated methods to differentiate wide complex tachycardias. In this review, we provide an in-depth
analysis of traditional and more contemporary methods to differentiate ventricular tachycardia and supraventricular wide com-
plex tachycardia. In doing so, we: (1) review hallmark wide complex tachycardia differentiation criteria, (2) examine the con-
ceptual and structural design of standard wide complex tachycardia differentiation methods, (3) discuss practical limitations
of manually applied ECG interpretation approaches, and (4) highlight recently formulated methods designed to differentiate
ventricular tachycardia and supraventricular wide complex tachycardia automatically.
Key Words: ECG ■ supraventricular tachycardia ■ ventricular tachycardia ■ wide complex tachycardia
W
ide complex tachycardia (WCT) is a general After decades of rigorous research, the quest for
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term that broadly denotes the presence of an effective, simplified, and practical means to non-
ventricular tachycardia (VT) or supraventricu- invasively differentiate WCTs has brought forth an
lar WCT (SWCT). As such, clinicians who encounter ever-expanding plethora of manually applied ECG
patients with a WCT must consider a broad variety interpretation methods.1–10 While manual methods
of attributable causes including VT, SWCT with pre- have proven their value in research settings, and can
existing or functional aberrancy, SWCT developing be readily adopted by clinicians, arriving at correct
from impulse propagation using atrioventricular ac- and timely VT or SWCT diagnoses remains a prob-
cessory pathways (ie, preexcitation), rapid ventricular lematic undertaking—even among experienced elec-
pacing, and tachyarrhythmias coinciding with toxic- trocardiographers. Recently, research has shown
metabolic QRS duration widening (eg, hyperkalemia that accurate WCT differentiation can even be ac-
or antiarrhythmic drug toxicity). Yet, without question, complished by automated approaches implemented
the most critical task for the clinician is to determine by computerized ECG interpretation (CEI) software
whether the tachyarrhythmia has a ventricular or su- programs.11,12
praventricular origin. Accurate discrimination of VT In this review, we provide an in-depth analysis of
and SWCT is incredibly vital as it impacts immediate traditional and contemporary methods to differenti-
patient care decisions, ensuing clinical workup, and ate WCTs. In doing so, we: (1) review hallmark ECG
long-term management strategies. Hence, proper pa- characteristics used for VT and SWCT differentiation,
tient management heavily relies on whether clinicians (2) examine the conceptual and structural design
are equipped with and appropriately apply effective of standard WCT differentiation methods, (3) high-
and reliable means to distinguish VT and SWCT. light practical limitations of manually applied ECG
Correspondence to: Adam M. May, MD, 660 South Euclid Avenue, CB 8086, St. Louis, MO 63110. E-mail: may.adam@wustl.edu
For Sources of Funding and Disclosures, see page 9.
© 2020 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative
Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and
is not used for commercial purposes.
JAHA is available at: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution
and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
in specific ECG leads (ie, V1–V2 and V6), (3) WCT QRS approximately half of VTs will demonstrate retrograde
duration, (4) chest lead concordance, (5) mean electri- ventriculoatrial conduction,1 wherein ventricular im-
cal axis (ie, QRS axis), (6) differences in ventricular ac- pulses conduct retrograde through the His-Purkinje
tivation velocity, and (7) dissimilarities compared with system to depolarize the atria. In such cases, VTs will
the baseline ECG. While all have proven their value in not exhibit atrioventricular dissociation; instead, they
distinguishing VT and SWCT, no single criterion or col- demonstrate a regular (eg, 1:1 ventriculoatrial con-
lection of criteria promises diagnostic certainty. duction) or an erratic (eg, ventriculoatrial conduction
with variable block) relationship.
Atrioventricular Dissociation
Wellens and colleagues1 highlighted the importance Morphological Criteria
of atrioventricular dissociation in 1978, which later ma- Meticulous examination of QRS configurations recorded
tured into one of the most trusted ECG criteria to secure in particular ECG leads (ie, V1–V2 and V6) may provide
VT diagnoses. As a general rule, VT may be confirmed essential clues as to whether a WCT has a ventricular or
once atrioventricular dissociation is assuredly identi- supraventricular origin. The pioneering works put forth
fied, especially when the ventricular rate exceeds the by Sandler and Marriott,13 Wellens et al1, and Kindwall
atrial rate. Unsurprisingly, several WCT differentiation et al14—collectively known as the “classical morphologi-
methods include atrioventricular dissociation as a key cal criteria”—have added considerable value towards
VT diagnostic criterion.2,3,8,9 However, although atrio- the diagnostic evaluation of WCTs (Figure 1).
ventricular dissociation may be quite valuable in estab- In general, the primary purpose of using the mor-
lishing VT diagnoses, its absence does not rule out VT phological criteria is to identify QRS configurations that
since it is often not electrocardiographically apparent, are consistent or inconsistent with aberrant conduction.
even among patients with known VT. If a WCT demonstrates a QRS configuration incompat-
By definition, atrioventricular dissociation is present ible with typical right or left bundle branch block pat-
when a self-governing ventricular rhythm autonomously terns, VT is the most likely diagnosis. For example, VT
subsists the atrial rhythm. Classically, atrioventric- would be the most likely diagnosis for a WCT demon-
ular dissociation is characterized by a series of QRS strating atypical right bundle block characteristics (eg,
monophasic R wave in V1 or V2 and QS pattern in to define VT diagnoses: QRS >140 ms for WCTs
V6). Conversely, if a WCT displays QRS configurations with right bundle branch block pattern and QRS
representative of typical right and left bundle aber- >160 ms for WCTs with left bundle branch block
rancy, SWCT is the most likely diagnosis. For example, pattern.15 However, since VT and SWCT occupy
SWCT would be the most probable diagnosis for WCTs broad and overlapping QRS duration ranges, the
demonstrating a classic left bundle branch block pat- sole use of WCT QRS duration cutoffs to differen-
tern (eg, r wave onset to S wave nadir <60 ms in V1 or tiate WCTs is unsatisfactory. A substantial propor-
V2 and notched monophasic R wave in V6). There are tion of SWCTs will display QRS durations >160 ms,
only a few notable exceptions to this concept, including especially among patients with ongoing antiarrhyth-
bundle branch reentry or fascicular VTs—each of which mic drug use, electrolyte disturbances, dramatic
rapidly engage the His-Purkinje network and can result conduction delays, or severe underlying structural
in fairly typical “aberrant” morphologies. heart disease or cardiomyopathies. On the contrary,
many patients demonstrating idiopathic VT variants
QRS Duration or VTs that arise from within or rapidly engage the
Ordinarily, VT primarily relies on an inefficient His-Purkinje system demonstrate QRS durations
means to depolarize the ventricular myocardium (ie, <140 ms (Figure 1). In rarer cases, VTs may dem-
cardiomyocyte-to-c ardiomyocyte conduction). As a onstrate substantial impulse propagation within the
result, VT commonly expresses longer QRS dura- conduction system and express QRS durations
tions than SWCT. This distinction was verified ini- <120 ms (eg, fascicular VT), thereby not fulfilling the
tially by Wellens and colleagues,1 and later spurred technical definition of WCT (ie, heart rate ≥100 beats
interest in proposed WCT QRS duration cutoffs per minute and QRS duration ≥120 ms).
Figure 2. Various wide complex tachycardia (WCT) differentiation algorithmic designs and algorithms.
AF indicates atrial fibrillation; AV, atrioventricular; LBBB, left bundle branch block; LR, likelihood ratio; RBBB, right bundle branch
block; RWPT, R wave peak time; SWCT, supraventricular wide complex tachycardia; and VT, ventricular tachycardia.
configurations in leads V1, II, and III compared with the Formula uses quantifiable QRS amplitude changes
preexisting bundle branch block during sinus rhythm (eg, frontal and horizontal percent amplitude change)
were nearly always SWCT, while WCTs with noticeably between paired WCT and baseline ECGs to estab-
different QRS configurations were usually VT. Later, lish an estimated VT probability.11 Similarly, the VT
in 1991, the multivariate analysis put forth by Griffith prediction model utilizes measurable changes in the
and colleagues21 verified that substantial deviation in QRS axis, T axis, and QRS duration between paired
QRS axis (ie, QRS axis change ≥40°) compared with WCT and baseline ECGs to determine VT likelihood.12
the baseline ECG was one of the most predictive ECG Such methods may be readily embedded into auto-
features to diagnose VT. More recently, Pachon et al9 mated ECG interpretation software systems to re-
utilized comparisons of QRS morphology between the duce the time necessary for an accurate diagnosis.
WCT and the baseline ECG as one of the weighty diag- However, it must be acknowledged that a distinct
nostic determinants within their point-based algorithm. disadvantage of these novel approaches is that they
Recently, we introduced novel WCT differen- require a baseline ECG (ie, an ECG recorded before
tiation methods,11,12,22 which leverage the magni- or after the WCT event) for their implementation.
tude of change between the WCT and baseline
ECG as a means to effectively distinguish VT and
SWCT (Figure 1). We described how universally STRATEGIC BLUEPRINTS FOR
available computerized measurements derived TRADITIONAL METHODS
from CEI software may be used to precisely quan- Decades of clinical research has brought forth a wide
tify specific changes between the WCT and base- variety of thoughtfully designed methods to differenti-
line rhythms.11,12,22 For example, the so-called WCT ate VT and SWCT. Separate from choosing the ideal
electrophysiological determinants to secure accurate by an algorithm helps ensure that it is readily recalled
WCT differentiation, algorithm creators were account- and easily implemented, this strategy ultimately in-
able for devising the organizational structure and op- creases the risk for overlooking other relevant di-
erative mechanics that will enable their algorithm’s agnostic ECG findings. For instance, clinicians who
generalized use. In the following sections, we: (1) re- choose to exclusively use the Vereckei aVR algo-
view the most common algorithm designs, (2) discuss rithm6 may paradoxically threaten near- certain VT
the overarching rationale behind their formulation, and diagnoses for WCTs demonstrating clear atrioven-
(3) examine the unique advantages and limitations for tricular dissociation.
each diagnostic approach.
VT as Default Diagnosis
Multistep Algorithms In 1994, Griffith et al3 introduced an alternative WCT
Without question, the most commonly utilized ap- differentiation method (ie, Griffith algorithm). For this
proaches to differentiate WCTs are the multistep algorithm, the authors devised a reversed strategy:
decision- tree algorithms, including the Brugada,2 VT is the default diagnosis, and SWCT diagnoses
Vereckei aVR,6 and limb lead algorithms10 (Figure 2). may be reached only when the classical criteria of
In general, multistep algorithms prompt users to ad- typical left or right bundle branch block is present
dress a series of sequentially applied inquiries, with (Figure 2). According to their algorithm, an SWCT di-
each step requesting the ECG interpreter to deter- agnosis may be made for WCTs displaying findings
mine whether a highly specific attribute of VT is pre- consistent with typical left bundle branch block (ie,
sent or absent. If an affirmative response is rendered rS or QS wave in leads V1 and V2, r wave onset to S
at any particular algorithm step, the algorithm’s ap- wave nadir <70 ms in leads V1 and V2, and mono-
plication is complete and a VT diagnosis is secured. phasic R wave without a q wave in lead V6) or right
On the other hand, before SWCT is diagnosed, the bundle branch block (ie, rSR’ morphology in lead
ECG interpreter must navigate through the entire al- V1, RS complex in lead V6, and R wave amplitude
gorithm and confirm that each step warrants a nega- greater than S wave amplitude in lead V6). Thus, if
tive response. In other words, SWCT diagnoses may a WCT does not demonstrate QRS configurations
only be reached once all highly specific attributes for classic for SWCT because of aberrancy, VT is the
VT, examined by the particular multistep algorithm, elected diagnosis. Hence, instead of relying on highly
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are absent. specific ECG criteria to rule in VT, highly specific ECG
In the early 1990s, Brugada and colleagues2 were criteria are used to rule in SWCT.
the first to conceptualize, organize, and then introduce The distinct advantage gained by using the Griffith
a multistep decision- tree algorithm design for WCT algorithm is that the majority of VTs will be correctly
differentiation. Their seminal work provided clinicians identified. However, although this reversed approach
with clear and straightforward steps to reach a defin- ensures strong diagnostic sensitivity for VT, it does
itive diagnosis. The authors hoped that the multistep so at the expense of its diagnostic specificity. In other
decision-tree design would help resolve more ambigu- words, since the Griffith algorithm deliberately limits
ous cases in which the WCT shares features support- the means to how an SWCT diagnosis is reached, a
ive of SWCT and VT. substantial number of SWCTs may be misclassified as
Since their inception, multistep algorithms have VT—especially those that demonstrate nonclassical
served as an excellent means for clinicians to wholly aberrancy or preexcitation.
commit to VT or SWCT diagnosis with reasonably
good diagnostic accuracy. Nevertheless, there are Bayesian Approach
notable limitations worth acknowledging. For exam- In 2000, Lau et al4 introduced a novel WCT differentia-
ple, one common problem is that clinicians are ordi- tion method centered around the use of LRs to distin-
narily left unapprised of the likelihood that their VT guish VT and SWCT. The so-called Bayesian algorithm
or SWCT diagnoses are accurate. Unless clinicians couples a predetermined “pretest odds of VT” with the
(1) are sufficiently informed of the performance met- predictive indices (ie, LRs) of a wide assortment of ECG
rics (eg, positive likelihood ratio [LR]) afforded by the criteria to secure a “posttest odds of VT.” For practical
algorithm step responsible for the diagnosis, and (2) use, the Bayesian algorithm assumes a pretest odds
accurately gauge the patient’s pretest probability for (ie, positive LR of 4) and multiplies this value by a com-
VT or SWCT, they will not have a precise determi- pilation of other LRs, each denoting the presence or
nation of whether their diagnosis is, in fact, correct. absence of specific ECG criterion (eg, positive LR of
Another limitation is that multistep algorithms pur- 50 for a monophasic QS in lead V6) (Figure 2). Once
posely examine a narrower scope of ECG attributes. the serial multiplication of LRs is complete, the posttest
Although restricting the number of criteria evaluated odds of VT (ie, LR) is established. If the final LR is ≥1,
VT is the diagnosis; if the final LR is <1, SWCT is the diagnoses may not be unequivocally present or absent
diagnosis. (eg, “Are those small deflections dissociated P waves
By conducting this mathematical procedure for or ECG artifact?”), and manual measurements essen-
a wide variety ECG features, the Bayesian algorithm tial for establishing the correct diagnosis may be at the
deliberately evades the 2 significant limitations that margin of predefined thresholds (eg, “Is the RS interval
commonly thwart hierarchal multistep algorithms: (1) convincingly <100 ms or ≥100 ms?”). Additionally, there
imperfect ascertainment (ie, presence or absence of are occasions where criteria tend to be quite vulner-
certain ECG criteria cannot be confirmed), and (2) in- able to human error and imprecision (eg, measurement
complete consideration of all relevant ECG features of Vi/Vt for minuscule QRS complexes in lead aVR).
(eg, outright VT diagnosis reached after just one algo- Furthermore, it is not rare for WCT to simultaneously
rithm step). However, this method mandates that the possess ECG characteristics consistent with both VT
interpreter engage in an intricate series of mathemat- and SWCT. Finally, we must also not overlook that
ical computations, which may be quite challenging to many diagnostically challenging VT subtypes (eg, fas-
accomplish while under duress. Additionally, because cicular VT or bundle branch reentry) routinely escape
the Bayesian algorithm considers each ECG criterion ECG criteria emphasized by standard WCT differentia-
to be an independent variable, the assigned LRs for tion methods.
individual variables are most likely overvalued. As a re- As a result of the aforementioned diagnostic chal-
sult, the final LR rendered by the Bayesian algorithm lenges, it is easy to see why subscribing to one or
may not accurately reflect the true likelihood for VT or more WCT methods that wholly commit to an absolute
SWCT diagnoses. VT or SWCT diagnosis is problematic. Consequently,
several authors chose to devise an alternative ap-
Single Criterion Method proach to differentiating WCTs (ie, point-based algo-
In 2008, Pava and colleagues7 proposed that a sin- rithms) (Figure 2).8,9 Rather than absolutely committing
gle, stand- alone criterion may distinguish VT and to a definite SWCT or VT diagnosis for every WCT,
SWCT accurately. In their analysis, they described point-based scoring methods purposely aim to iden-
the procedure of measuring the RWPT in lead II as tify WCTs with near-certain VT or SWCT diagnoses.
a simple-to-use, highly specific, and highly sensitive For example, the point-based algorithm put forth by
means to discriminate VT from SWCT. As described Jastrzebski et al8 (ie, the VT score) has demonstrated
the capacity to confirm VT with near certainty for a
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applied interpretation approaches are entirely de- the use of logistic regression modeling—a procedure
pendent on the competency of the ECG interpreter, that may operate independently of clinicians’ ECG
and therefore are quite vulnerable to improper ap- interpretation competency. Prospective and forth-
plication or abstained use. As a consequence, the coming methods will similarly deliver unambiguous
generalized usage of manual ECG interpretation estimations of VT probability using machine learning
methods is unsurprisingly problematic—particularly modeling techniques (eg, artificial neural networks
for clinicians who must promptly diagnose and man- or random forests). By these means, clinicians will
age high-acuity patients.24–27 be able to integrate estimated VT probabilities with:
Another relevant, but often overlooked, limita- (1) diagnoses reached by other WCT differentiation
tion stems from the fact that WCT differentiation methods (eg, Brugada algorithm or the VT score),
methods were uniformly derived2,5–8,21 and inde- and (2) other particularly important diagnostic de-
pendently validated8,23,25,26,28 using select investi- terminants (eg, history of structural heart disease or
gational groups (ie, only patients who undergo an myocardial infarction). Once incorporated in CEI soft-
electrophysiology procedure) and controlled exper- ware platforms, automated methods may substan-
imental conditions (ie, ECG interpretation performed tially help clinicians accurately distinguish VT and
by heart rhythm experts separated from the actual SWCT.
clinical settings in which the WCT presented). In fact, As we progress further into an era that will be
to date, only one validation study has assessed di- dominated by automation and machine learning,
agnostic performance using a broader collection of the prospect of integrating sophisticated and highly
WCTs expected to be encountered in “real-life” clin- accurate processes into computerized software to
ical practice (ie, evaluating WCTs from patients with accurately differentiate WCTs is not far away. By
and without an accompanying electrophysiology solely analyzing 12-lead ECG recordings, machine
study).27 Consequently, it remains largely unknown learning techniques have already shown the ability
whether the diagnostic performance of standard to predict age and sex, as well as detect left ven-
WCT differentiation algorithms or criteria would be tricular systolic dysfunction and hypertrophic car-
sufficiently preserved when they are implemented in diomyopathy.30–33 Thus, it seems increasingly likely
actual clinical practice. Unfortunately, a clear under- that automated processes that leverage the power
standing of the overall practical value of conventional of machine learning will one day help escape the
WCT differentiation methods will likely never be real- limitations that plague traditional WCT differentiation
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ized, as it would not be feasible to prospectively test approaches and enable highly accurate and timely
their diagnostic performance within genuine clinical WCT differentiation. It is through the development,
circumstances. refinement, and eventual integration of sophisticated
automated approaches into CEI software we can
hope to transform WCT differentiation into an anti-
NOVEL METHODS AND FUTURE quated diagnostic dilemma.
DIRECTIONS
Ideally, reliable WCT differentiation would occur imme- CONCLUSIONS
diately upon 12-lead ECG acquisition. Unfortunately, Decades of research have produced a rich literature
currently available CEI software programs have not yet base and an expanding myriad of diagnostic ap-
achieved sufficient diagnostic accuracy for complex proaches to help clinicians accurately differentiate
heart rhythms,29 including WCT differentiation. As a re- WCTs. Traditional manually applied WCT differentia-
sult, clinicians must rely primarily on traditional manu- tion methods have proven their value in distinguish-
ally applied ECG interpretation methods to render an ing the majority of WCTs; however, they uniformly
accurate VT and SWCT diagnosis. depend on the ECG interpreter for their implementa-
However, our recent work has challenged this tion, rendering them particularly susceptible to their
limitation with several novel automated methods to improper execution or refrained utilization. Promising
distinguish VT and SWCT accurately.11,12 Through automated WCT differentiation methods that make
the use of readily available ECG data routinely pro- use of CEI software programs are beginning to
cessed by CEI software, well-established and math- emerge, signaling the eventual introduction of novel
ematically formulated VT predictors (eg, frontal and alternative solutions to effectively distinguish VT and
horizontal percent amplitude change) may be used SWCT.
to yield accurate VT and SWCT predictions automat-
ically. A central feature of these methods is that they
provide clinicians an impartial estimation of VT like- ARTICLE INFORMATION
lihood (ie, 0.00% to 99.99% VT probability) through Received March 19, 2020; accepted April 13, 2020.
Affiliations 15. Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS
From the Departments of Medicine (A.H.K.), and Cardiovascular Diseases complex tachycardia. Reappraisal of a common clinical problem. Ann
(P.A.N., C.V.D., A.J.D., S.J.A.), Mayo Clinic, Rochester, MN; Cardiovascular Intern Med. 1988;109:905–912.
Division, Washington University School of Medicine, St. Louis, MO 16. Marriott HJ. Differential diagnosis of supraventricular and ventricular
(A.M.M.). tachycardia. Geriatrics. 1970;25:91–101.
17. Barold SS, Stroobandt RX, Herweg B. Limitations of the negative
Sources of Funding concordance pattern in the diagnosis of broad QRS tachycardia. J
This work was supported by the Department of Cardiovascular Diseases at Electrocardiol. 2012;45:733–735.
Mayo Clinic in Rochester, MN. 18. Miller JM, Das MK, Yadav AV, Bhakta D, Nair G, Alberte C. Value of the
12-lead ECG in wide QRS tachycardia. Cardiol Clin. 2006;24:439–451,
Disclosures ix–x.
Adam May, Chris DeSimone, and Abhishek Deshmukh are obliged to dis- 19. El Hajjaji I, Becker G, Kus T, Vinet A, Berkovitz A, Sturmer M. Novel
close that they are “would-be” beneficiaries of intellectual property that is criterion for the differential diagnosis of wide QRS complexes and wide
briefly discussed in the article. The remaining authors have no disclosures complex tachycardia using the initial activation of QRS on leads V1 and
to report. V2: differential diagnosis of wide QRS based on V1-V2. J Electrocardiol.
2018;51:700–706.
20. Dongas J, Lehmann MH, Mahmud R, Denker S, Soni J, Akhtar M. Value
of preexisting bundle branch block in the electrocardiographic differen-
tiation of supraventricular from ventricular origin of wide QRS tachycar-
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