Differential Diagnosis of

Tachycardias

Differential diagnosis of broad complex tachycardias

Criteria for the diagnosis of the presence of a

broad complex tachycardia:
QRS >120ms = Broad Complex Tachycardia
QRS <120ms = Narrow Complex Tachycardia

Tachycardias
Narrow QRS
Sinus tachycardia
Atrial tachycardia
Atrial fibrillation
Atrial Flutter
AVRNT
AVRT
SVT

Broad QRS
Ventricular tachycardia
SVT with abnormal
conduction
Bundle branch block
Rate related
Ventricular preexcitation

Differential diagnosis of broad complex tachycardias

The rhythm strip taken from a single lead is

generally insufficient to make a differential
diagnosis between an SVT with aberrancy
or VT. A 12 lead ECG is required for
making an accurate diagnosis.

Differential diagnosis of broad complex tachycardias

The presence of anyone of the following confirms the
diagnosis of VT:
Evidence of A.V.Dissociation.in the form of
independent atrial activity.
Presence of fusion beats
Presence of capture beats

AV dissociation

Atrioventricular dissociation in
monomorphic ventricular tachycardia
(note P waves, arrowed)

Capture beat

Capture beat

Fusion Beat

Fusion beat

Differential diagnosis of broad complex tachycardias

In patients with IHD. .
90% of broad complex
tachycardias will be ventricular
in origin

QRS Contours Favouring Ventricular Tachycardia

V1

V1

V6

Wellens

Gulamhusein

15/15 (100%)

84/86 (98%)

7/7 (100%)

177/187 (95%)

27/31 (87%)

189/190(100%)

V6

17/17 (100%)

38/40(94%)

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.

Differential diagnosis of broad complex tachycardias

QRS Contours Favouring Ventricular Aberration
V1

V6

Wellens

Gulamhusein

38/41 (93%)

55/55 (100%)

44/47 (94%)

27/27 (100%)

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

V1

SVT is more the likely

diagnosis where there is
a triphasic QRSrSR;
with the R wave taller
than the initial r.

Professor A.J Camm: A Master Class in The Differential Diagnosis

of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

V1

If the S wave at least

reaches the isoelectric
line (or goes beyond it)
the tachycardia is most
likely to be supraventricular in origin.

Professor A.J Camm: A Master Class in The Differential Diagnosis

of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern
NB: Proviso:

V1

If the S wave is not

much more than a notch
on the down-stroke, then
the tachycardia is less
likely to be
supraventricular in origin.

Professor A.J Camm: A Master Class in The Differential Diagnosis

of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

V6

R:S >1

R:S <1

SVT

VT

Professor A.J Camm: A Master Class in The Differential Diagnosis

of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern

V1

Kinwall Criteria:

The Presence of any one of these characteristics points

to the diagnosis of VT.
Initial r wave in V1 > 30ms in duration.
Presence of a notch on the down-stroke of the S
wave.
The duration of the complex from the start of the r
wave to the nadir of the S wave = 60ms or more.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern
30ms

notch

V1
60ms
Professor A.J Camm: A Master Class in The Differential Diagnosis
of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern

V6

The presence of any q

wave points to the
likelihood that the
tachycardia is
ventricular in origin.

Professor A.J Camm: A Master Class in The Differential Diagnosis

of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Brugarder et al Criteria:
rS patterns are usually present in one or more
precordial leads therefore:
A no rS pattern most likely suggests that the
tachycardia is ventricular in origin.
If there are any rS complexes; if the distance
from the start of the r wave to the nadir of the S
wave is 100ms or more it indicates that the
tachycardia is most likely to be ventricular in origin.

Differential diagnosis of broad complex tachycardias

V1 V6
100ms
Professor A.J Camm: A Master Class in The Differential Diagnosis
of Broad Complex Tachycardias.

Differential diagnosis of broad complex tachycardias

Concordance of The QRS complexes in The Precordial Leads
When all of the ventricular complexes from leads V1 to
V6 are either negative (concordant precordial negative) or
positive (concordant precordial positive), the diagnosis is
most likely VT, since these patterns would be atypical of
either RBBB or LBBB.
Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.

Differential diagnosis of broad complex tachycardias

Negative Concordance

Positive Concordance

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.

Cardiac Axis:

If the Cardiac axis is between -150

and
-/+ 1800, this is clearly abnormal and is a
useful clue to the tachycardia being
ventricular in origin since the electrical axis
of neither RBBB or LBBB produce such
extreme axis deviation.
0

Broad complex Tachycardia

yes
Independent p waves visible

VT

no

Are QRS in V1 and V6 typical for left or

right BBB
yes

SVT a possibilty

no
VT