Wide QRS Tachycardia

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 Definition
• Wide QRS tachycardia is tachycardia having a
QRS duration of > 120 milliseconds (ms).

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 Mechanisms for Wide QRS
Tachycardia
• supraventricular tachycardia (SVT) with
aberrant conduction
• pre-excited tachycardia
• ventricular tachycardia (VT)
• pacemaker-mediated tachycardia

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 Clinical Assessment

• History
- younger patient with recurrent tachycardia
favors SVT with aberrancy or pre-excited
tachycardia
- older patient with structural heart disease,
e.g. coronary disease, favors VT

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 Clinical Assessment (con’t.)
• Physical examination
- hemodynamic status
- carotid sinus massage
- evidence of AV dissociation
• cannon A waves on jugular venous pulse
• variable intensity of the S1
• variability in systolic blood pressure

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 ECG Assessment
• 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

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 AV Dissociation
• independent atrial and ventricular
activation
• seen in 50% of patients with VT
• exceedingly rare in SVT
• best seen in leads V1 and inferior leads
• “Lewis” lead amplifies P waves

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 Capture and Fusion Beats
• dissociated P wave totally (capture) or
partially (fusion) activates the ventricle in
advance of the next VT cycle.
• appears as a premature “narrow” QRS
complex during VT
• highly specific for VT
• infrequently seen

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 QRS Width

• consider VT if:
- RBBB pattern > 140 ms
- LBBB pattern > 160 ms

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 QRS Axis
• normal axis favors SVT
• left or right axis deviation favors VT
• extreme left or right axis deviation
(“northwest”) axis strongly favors VT

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 QRS Irregularity
• 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

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 QRS Concordance
• strongly favors VT
• positive concordance (positive QRS in V1
to V6) suggests posterobasal origin
• negative concordance (negative QRS in
V1 to V6) suggests anteroapical origin

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 QRS Morphology
• leads V1 and V6 most useful
• a very “typical” right or left bundle branch
block pattern is more likely to be SVT and a
very “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

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 QRS Morphology Favoring
SVT
• RBBB morphology QRS
- triphasic pattern with rsR` or rR` in V1
- qRs in V6
• LBBB morphology QRS
- rS (r < 30 ms; rapid downslope of S) or QS
in V1
- monophasic R in V6

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 QRS Morphology Favoring VT
•RBBB morphology QRS
-monophasic or biphasic in V1; R > R’
-rS or QS in V6
•LBBB morphology QRS
-rightward axis
-broad R wave (> 40 ms); notching in the
downslope of the S wave in V1
-qR or QS in V1
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Ancilliary Investigations

• echocardiography
• esophageal ECG
• pharmacologic maneuver
- e.g., adenosine

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 Therapy for Wide QRS
Tachycardia
• if patient is hemodynamically unstable, prompt
electrical cardioversion is indicated

• if patient is stable, and tachycardia mechanism

is uncertain, therapeutic trial with:
- adenosine
- procainamide
- lidocaine
- Cardioversion

• avoid verapamil unless VT has been ruled out

with certainty
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When in doubt, the working
diagnosis is VT until proven
otherwise!

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