Clinical Arrhythmias

Wide Complex Tachycardia – Ventricular Tachycardia or Not Ventricular Tachycardia,

That Remains the Question
J ohn B G a r n e r 1 a n d J o h n M M i l l e r 2

1. Cardiac Electrophysiology Fellow; 2. Professor of Medicine and Director, Clinical Cardiac Electrophysiology and Training Program, Indiana University
School of Medicine, Indiana, US

Abstract
Arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians. In this paper, we review
the historical development of criteria used to differentiate among the major diagnostic possibilities and compare the strengths and
weaknesses of various differentiating algorithms.

Keywords
Ventricular tachycardia, supraventricular tachycardia, aberration, wide complex tachycardia

Disclosure: John B Garner has no conflicts of interest to declare. John M Miller receives funding, grants or honoraria from Medtronic, Inc., Boston Scientific Corp.,
Biosense-Webster, Inc., Biotronik, Inc., St Jude Medical (training support, lecturing), Stereotaxis, Inc., and Topera, Inc. (advisory board services).
Received: 10 November 2012 Accepted: 20 January 2013 Citation: Arrhythmia & Electrophysiology Review 2013;2(1):23–29 Access at: www.AERjournal.com
Correspondence: John M Miller, Indiana University School of Medicine, Krannert Institute of Cardiology, 1800 N. Capitol Ave, Indianapolis, IN 46202, US. E: [email protected]

A wide complex tachycardia (WCT) is simple enough to define: a insulation of the mitral or tricuspid valve annulus. As a result of their
cardiac rhythm with a rate >100 beats per minute and a QRS width locations, ventricular activation during sinus rhythm occurs basally
>120 milliseconds (ms). Unfortunately, beyond this simple definition lies and epicardially. Since the AVN/HPS are also activated with each
a complex differential diagnosis with prognoses ranging from utterly atrial impulse, the resulting QRS is usually a fusion of activation,
benign to potentially lethal, requiring treatment strategies ranging from with the initial component arising from the AP (the delta wave)
medications to emergent non-sedated cardioversion and implantable and the latter part of the QRS a fusion between normal activation and
cardioverter defibrillator (ICD) implantation (see Table 1). Practically, the continuing wavefront from the AP. During atrial fibrillation, this
however, the differential diagnosis typically devolves to the question of manifests as irregular wide complex beats with variable QRS width
ventricular tachycardia (VT) versus supraventricular tachycardia (SVT) with caused by varying proportions of conduction over the AVN/HPS and
aberration. An intelligent, organised approach to WCTs is crucial to all pathway. Rare APs also exist between the specialised conduction
practitioners responsible for the interpretation of an electrocardiogram tissues and the ventricle, but are infrequent enough to place them
(ECG), whether in emergency medicine, cardiology or primary care. outside the scope of this review.

Aberrancy – From A to V Via Pacemaker

Via Normal Conduction System with Aberrancy In some ways, a pacemaker can be thought of as an accessory
There exist only four ‘aberrant’ ways an atrial impulse can conduct over pathway inserting at the site of the ventricular lead(s). Depending on
the atrioventricular (AV) node (AVN) and His-Purkinje system (HPS) to the the lead’s tip location, a host of activation sequences are possible,
ventricles: right bundle branch block (RBBB), RBBB with either left or right especially if the HPS is also contributing to activation. Obviously, the
hemiblock and left bundle branch block (LBBB). As a first approximation, presence of a pacing device on physical examination is a strong clue
if the QRS complex during WCT cannot be resolved as using one of these to this possible diagnosis. Modern bipolar pacemakers use so little
four routes, the ventricle must be activating outside the specialised voltage, confined to such a small area, that pacemaker spikes are
conduction tissue, limiting the differential to VT or SVT with ventricular frequently difficult to discern or are even invisible on the ECG. Modern
activation over an AV accessory pathway (AP). Rarely, do patients with ECG systems compensate for this by adding artificial pacing spikes
unusual hypertrophy patterns or repaired congenital heart disease have when they detect the frequency characteristics of a pacing output, but
bizarre, wide QRS patterns during sinus rhythm; SVT in these patients this feature is imperfect in its ability to detect these impulses.
will thus be similarly bizarre, potentially causing an SVT to appear most
unusual for what is otherwise ‘normal’ conduction. Though this group Do We Need an Algorithm at All?
of patients is growing in size, it remains a small proportion of all WCTs. Pre-test Probability
Multiple prior series have shown that, due to prevalence alone,
Via Pathway the pre-test probability of a WCT being VT is in excess of 80 %.1–4
Extranodal APs are abnormal muscle-to-muscle connections between That is to say that if a reader simply declares all WCTs to be
atrium and ventricle across what should be the complete electrical VT, that irresponsible individual will still be correct four out of five

© RADCLIFFE 2013 23
Clinical Arrhythmias

Table 1: Differential Diagnosis of Wide Complex Table 2: Predictive Values and Accuracies of the Most
Tachycardia Common Ventricular Tachycardia Criteria u

1) Ventricular tachycardia Original Paper Later Studies

2) Supraventricular tachycardia: In RBBB and LBBB Morphologies Positive Predictive Value
A) with aberrancy in the His-Purkinje system AV dissociation → VT 100 %11 100 %9,10,12,13
B) with anterograde accessory pathway conduction Precordial concordance → VT 100 %8 89–100 %7,10
C) with bizarre baseline QRS ‘Northwest’ axis (>270 °) → VT – 95–96 %10,22
D) in presence of drug effect or electrolyte imbalance
In RBBB Morphology Only Positive Predictive Value
3) Ventricular pacing
V1: Rsr’ (Left peak > right) → VT 100 %11 100 %9,22
4) Electrocardiogram artefact
Left axis deviation → VT 94 % 11
88*–96 %9,10,22
QRS width >140 → VT 100 %11 89 %10
V1: Mono- or biphasic QRS → VT 97 %11 82–100 %7,9,22
times. Furthermore, if the patient is known to have prior myocardial
V6: R to S ratio <1 → VT 90 %11 90–100 %10,22
infarction, and symptoms of tachycardia did not begin until
V1: rSR (S crosses baseline) → SVT 91 % 6
93 %11
some time after the infarction, the odds of a WCT being VT exceed
In LBBB Morphology Only Positive Predictive Value
90 %. 3,4 The bar is thus set high for a differentiating algorithm to
QRS duration > 160 ms → VT 100 %11 98–99 %10,22
significantly improve on this accuracy in revealing the true diagnosis
Right axis deviation → VT 100 % 11
87–96 %9,10
of WCT. V1 or V2: Initial r >30 ms → VT 100 %14 –
V1 or V2: Onset of r to nadir of 98 %14 –

Kindwall
Importance of the Diagnosis S >60 ms → VT
At Presentation V1 or V2: Notched downstroke → VT 97 %14 –
The primary goal of a correct diagnosis at presentation is the avoidance V6: Any q wave → VT 100 %11 98 %14
of harm. An SVT incorrectly believed to be VT may be treated with Algorithms Diagnosing Both VT and SVT Accuracy
amiodarone or electrical cardioversion – not optimal therapy, but not Any 1 of 4 Kindwall criteria above → VT 98 %14 92 %22
harmful. If the presenting rhythm was instead atrial flutter, cardioversion The combined Brugada algorithm 98 %12 78–79 %16,17
in an unanticoagulated patient will incur a 1.5 % risk of stroke, harming aVR algorithm 92 %13 72 %16
one in every 66 patients.5 Worse still is the patient with VT treated as SVT. Griffith algorithm 86 % 20
78–79 %16,17
Lead II deflection >50 ms → VT, else SVT >90 % ** 19
69 %16
In this case, agents with negative inotropic effects such as verapamil
or diltiazem may be used to control the presumed SVT. In one series, ‘One-sided’ criteria (those suggesting only SVT or VT) do not suggest the opposite diagnosis
in their absence. Most of these criteria are visually depicted in Figure 1.
100 % of patients given verapamil for an inappropriate diagnosis of SVT
AV = atrioventricular; aVR = augmented vector right; LBBB = left bundle branch block; RBBB
had haemodynamic deterioration.1 This mistake must thus be avoided if = right bundle branch block; SVT = supraventricular tachycardia; VT = ventricular tachycardia.
* The study reporting 88 % certainty for this criteria used axis <0 °; others used axis <-30 °.
at all possible.
** The source article contains insufficient information for direct calculation of accuracy.

In Later Management
The more insidious consequences of misdiagnosed arrhythmia are Principles of Ventricular Tachycardia
found in the long term management of such patients. Incorrectly Discrimination
diagnosing an SVT as VT may result in the patient receiving long-term Basis and Goals of Ventricular Tachycardia Criteria
amiodarone therapy, or even an implantable defibrillator with repeated In contrast to the SVTs described above, with relatively constrained
generator changes ahead. Regardless of which rhythm is misdiagnosed, modes of ventricular activation, VT can originate from literally
potentially curative catheter-based therapies may be inappropriately any location within the ventricular myocardium or its specialised
withheld from the patient. conduction tissues. As a result of this, VT can appear identical to
any of the wide complex SVTs above and it is nearly impossible
Common Mistakes in Diagnosis to say with absolute certainty, from an ECG of free-running
It is a common misconception that a haemodynamically stable tachycardia alone, that a wide complex rhythm must be
patient with minimal symptoms during a WCT episode must supraventricular. As such, most algorithms seeking to discriminate
have SVT. 2 The converse is likewise untrue. Often adding to this the two entities focus on identifying characteristics unique to VTs
assumption is a belief that termination by adenosine or verapamil – that is to say, those with high specificity for VT – and presume all
proves SVT. Again, this assumption can lead to misdiagnosis as else to be SVT until proven otherwise; the Griffith algorithm is the
some VTs are responsive to one or both of these agents. Fortunately, notable exception to this approach. Algorithms have been unable
the vast majority of these VTs are not associated with significant to reliably distinguish between VT and pre-excited SVT, since initial
structural heart disease and sudden death with episodes is ventricular activation in the latter is (like most VTs) extrinsic to the
extraordinarily rare. normal conduction system. Since pre-excited SVTs comprise such
a small proportion of WCTs, they will not be considered further in
Maintaining Focus on the Patient this discussion.
The exercise of trying to apply algorithms to diagnose a WCT can distract
a providers’ attention from the patient. Immediate cardioversion of Defining Morphology
the haemodynamically unstable patient with WCT should be the first One of the first determinations in looking at a WCT should be its
thought, and only when some measure of stability has been achieved bundle branch block morphology. Ordinarily, the term bundle branch
should a provider delay care to look up and apply the various algorithms block (BBB) implies failure to conduct over one or more of the
described below.1 specialised fascicles, but in discussion of WCT, the question is

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 Wide Complex Tachycardia

Figure 1: Morphological Criteria for Discriminating Ventricular Tachycardia from Supraventricular Tachycardia
VT Discrimination Quick Reference
with Aberration
figures by J. Garner, MD and J. Miller, MD

AV Dissociation is Always VT Determining Bundle Branch Type Brugada Algorithm

RBBB Morphology LBBB Morphology 1 No Precordial Lead has Both R and S
QRS complexes faster than, and independent of, P waves (V1 Final Deflection Positive) (V1 Final Deflection Negative)
2 Onset of R to Nadir of S >100 ms
in ANY of V1-V6

V any
Fusion Beat

QRS Duration Axis 3 AV Dissociation

Right Superior In RBBB, Left Axis In LBBB, Right Axis
QRS Duration > 160 ms In RBBB Morphology Axis Suggests VT Also Suggests VT Also Suggests VT Morphology Criteria:
4
Always Suggests VT QRSd > 140 ms Suggests VT
Both V1 and V6 Suggest VT VT
Suggests VT Strongly
Does not exclude VT
if RBBB-type Suggests VT None of the Above SVT
140 160
Lead aVR Algorithm
RBBB Morph. Criteria for VT LBBB Morph. Criteria for VT Initial Initial r Wave
Dominant R > 40 ms
QR R > R’ Onset of r to Notched
Monophasic R (Biphasic QRS) “Rabbit Ear” Initial r > 30 ms Nadir of S > 60 ms Downstroke 1 2
V1
or
V1 Initial q Wave Notched Downstroke
V2 > 40 ms of Negative QRS

3 4
R wave < S wave QS or QR Monophasic R
(R:S ratio < 1) (Dominant Q) (No q, s or r’) Any q Wave QS or QR
Voltage Change in Last 40 ms ≥
V6 V6 Voltage Change in First 40 ms of QRS

RBBB Morph. Criteria for SVT LBBB Morph. Criteria for SVT 5

Triphasic QRS (rSR’) RS Complex Monophasic R

(Esp. if S crosses baseline) R wave > S wave (No q Wave)

V1 V6 V6 Any of the above in lead aVR ➜ VT

None of the above in lead aVR ➜ SVT

AV = atrioventricular; aVR = augmented vector right; LBBB = left bundle branch block; RBBB = right bundle branch block; SVT = supraventricular tachycardia; VT = ventricular tachycardia.

Figure 2: Several Criteria Correctly Identify Right Bundle Branch Block Supraventricular Tachycardia

A: QRS duration <140 ms; B: QRS configuration is rSR’; C: R/S ratio in V6 >1; D: R–S duration in precordial lead with RS complex <100 ms; E: aVR with sharp Q followed by R wave; F: QRS onset
to peak in lead II <50 ms. Each of these criteria correctly point to a diagnosis of SVT.

designed more to evaluate which chamber activates last. This is done Specific Ventricular Tachycardia Algorithms and
by looking at the terminal deflection of lead V1. A LBBB WCT is one Their Performance
with a terminal negative deflection in V1 and RBBB is then a positive In Table 2, we list many of the most popular VT criteria. Where a
terminal deflection. criterion is to be applied only to one BBB pattern or another, this

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Figure 3: Several Criteria Correctly Identify Right Bundle Branch Block Ventricular Tachycardia

A: QRS duration >140 ms; B: QRS configuration is monophasic R; C: R/S ratio in V6 <1; D: R–S duration in precordial lead with RS complex >100 ms (favours VT); E: aVR with slurred Q wave
(favours VT); F: QRS onset to peak in lead II >50 ms. Each of these criteria correctly point to a diagnosis of VT.

Figure 4: Criteria Incorrectly Suggests Ventricular Tachycardia in this Patient with Right Bundle Branch Block
Supraventricular Tachycardia and Prior Myocardial Infarction

A: QRS duration 140 ms (equivocal); B: QRS configuration is qR (favours VT); C: R/S ratio in V6 <1 (favours VT); D: absent RS in precordial leads (favours VT); E: aVR with monophasic R wave
(favours VT); F: QRS onset to peak in lead II <50 ms (favours SVT).

is listed before the criterion as [RB] or [LB] for RBBB and LBBB, Sandler and Marriott Criteria (1965)
respectively. Many of these criteria (e.g. AV dissociation = VT) • [RB] Identical activation vector = SVT. If the initial 20 ms of the QRS
suggest one diagnosis, but do not exclude the opposite diagnosis. are the same in WCT as in sinus rhythm, SVT is favoured by 20:1,
For such criteria, a predictive value is listed. For algorithms that with a positive predictive value (PPV) of 92 %.6 Of course, the
can give both SVT and VT as possible answers, we report overall sinus rhythm ECG must be available for this analysis.
accuracies. In all cases, these numbers were stated explicitly in the • [RB] An rSR’ where S crosses baseline = SVT. The presence of
original reports or derived from them using standard formulas and such a QRS in a RBBB WCT favours SVT by at least 11:1 with a
2x2 tables. PPV of 91 %.6
• [RB] Triphasic QRS = SVT. A triphasic QRS in V1 favoured SVT with
Foundations – The Morphology Criteria a PPV of 92 %.6 This criterion’s distinguishing power performs
The work of Sandler and Marriott published in 1965 laid the well even in studies designed to minimise the performance of VT
foundation for the use of ECG criteria instead of, or in complement criteria, with specificity ≥90 %.7
to, physical exam skills for the diagnosis of VT. Their pioneering work • [RB, LB] Precordial concordance = VT. A QRS, which is predominantly
showed that conventional assumptions about how normal ECG positive or predominantly negative in every precordial lead,
patterns ‘should’ present were often misleading. From analysis of overwhelmingly favours VT.8 Subsequent studies have confirmed
100 premature ventricular contractions (PVCs), 50 RBBB aberrancies this with specificity of 95–100 % and a PPV of 89–100 %.7,9,10
and 100 fixed RBBBs, they drew many conclusions, a few of which
have withstood the test of time. The generally accepted morphology The Wellens Criteria of Right Bundle Branch Block
criteria from their work as well as that of other investigators are By 1978, two advances had allowed a leap forward in the ECG criteria:
summarised in Figure 1. the development of the His bundle electrogram and simultaneous

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 Wide Complex Tachycardia

Figure 5: Criteria Incorrectly Suggests Supraventricular Tachycardia in this Patient with Idiopathic Left Bundle Branch
Block Ventricular Tachycardia

A: QRS duration 130 ms (favours SVT); B: onset QRS-S wave nadir 60 ms (favours SVT); C: R–S duration in precordial lead with RS complex >100 ms (favours VT); D: aVR with wide Q wave
(favours VT); E: QRS onset to peak in lead II >50 ms (favours SVT).

multi-lead electrocardiography. Using these new tools, Wellens et left R wave taller than the right, and the S wave not crossing the
al. analysed 70 sustained VT and 70 SVT episodes with aberrancy, baseline, was invariably associated with VT; subsequent study
all proven at electrophysiological study.11 Though the criteria set has confirmed this 100 % PPV.9
forth in this paper are often discussed only in terms of their
contributions to discriminating RBBB tachycardias, this paper also The Kindwall Criteria of Left Bundle Branch Block
offered observations on LBBB morphology that would be used by Building on the observations of V6 behaviour in LBBB noted by
later authors. As they are commonly used today, Wellens’ criteria for Wellens and others, Kindwall and Josephson published the first
RBBB VT are as follows: and still most common criteria specific to LBBB WCT.14 Each of
the criteria alone has poor sensitivity but high specificity (and thus
• [RB] QRS duration >140 ms = VT. The original data showed a high PPV, ≥97 %). To remedy this, the criteria are applied such that
specificity and PPV of 100 % for VT. Subsequent studies found presence of any of the four criteria indicates VT, with an overall
this less certain, with specificities of 57–75 % and PPV of 89 %.7,10 accuracy of 97.5 % in the original study and excellent performance
• [RB] Left axis = VT. This was originally discussed without regard in subsequent literature.9
to bundle block morphology, but it is most robust for RBBB WCT
where the original PPV was 94 %. Later studies have found PPVs These criteria are:
of 88–94 %.9,10 With extreme left axis (more negative than -90 °),
the PPV is 98 %. • [LB] V1 or V2 with initial R >30 ms = VT.
• AV dissociation = VT. Of all criteria, this is the most secure. Six separate, • [LB] V1 or V2 QRS onset to nadir of S wave >60 ms = VT.
large cohorts have all found 100 % specificity and 100 % PPV for true • [LB] V1 or V2 with notching on the S wave downstroke = VT.
AV dissociation as a marker of VT.9–13 It holds true regardless of bundle • [LB] Any Q in V6 = VT.
branch pattern or other morphology criteria. Its weakness is being able
to confidently recognise its presence; in many cases, even when AV The Brugada Criteria
dissociation is clearly present on intracardiac recordings during VT, it Published in 1991, the Brugada criteria were the first to offer
cannot be readily seen on the ECG. applicability to all WCT without limitation to one BBB configuration
• [RB] Morphology criteria. Wellens built on the observation of or another. The original paper reported overall accuracy of 98 %.
Sandler and Mariott that mono- or biphasic V1 QRS morphologies However, no subsequent study has been able to achieve such results,
in a RBBB WCT suggests VT. Though the original paper found with the overall accuracy of the algorithm 77–85 % across four large
a 97 % PPV for this statement, later study has been unable to studies.13,15–17 Most authors note difficulty in applying the last step
confirm this; finding a PPV of only 82–83 %.7,9,12 If the V1 QRS is of the criteria (the morphology section), particularly among non-
triphasic, Wellens’ criteria suggests investigation of V6 for an R:S cardiologists. The criteria are applied in stepwise fashion, stopping
ratio <1 (that is, R wave smaller than S wave) as suggesting VT. further analysis if any step suggests VT.
This criterion had a modest 90 % PPV both in the original data and
subsequent evaluation.10 • Step 1: Absence of RS complex anywhere in V1–V6 = VT.
• [RB] ‘Rabbit ears’ Rsr’ = VT. Aside from the four well-known criteria • Step 2: Onset of R to nadir of S in any precordial
above, Wellens noted that an unusual triphasic V1, with the lead >100 ms = VT.

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Clinical Arrhythmias

• Step 3: AV dissociation = VT. and in subsequent evaluation.16,17,20 Of note, right ventricular outflow tract
• Step 4: Morphology criteria (see Figure 1 for details). Of particular tachycardias are frequently misclassified as SVT by this algorithm, and
note, both V1 and V6 must suggest VT for the diagnosis to be should be evaluated with other criteria by users of this algorithm.
made; otherwise, SVT is the diagnosis.
Embracing the Unknown – Bayesian Analysis
Recognising that the morphology criteria can be difficult to remember, A Bayesian algorithm has been validated, which recognises that a
some advocate using only steps 1 and 2. The results of this approach definitive answer is not always possible for any given criteria. This
have been variable with PPV for VT of 81–96 % in two different unique algorithm relies on likelihood ratios and a pre-test odds ratio of
studies.10,17 4 (representing the 80+ % chance a given WCT will be VT) to compute
a final likelihood of VT from any number of its component criteria,
The Vereckei Criteria of Augmented Vector Right and readily lends itself to the addition of new criteria as they emerge,
Vereckei et al. were the first to suggest the possibility of diagnosis of VT though these would require validation in another cohort.9
in either left or right BBB WCT from a single lead – augmented vector
right (aVR) in this case.18 In similar fashion to the Brugada criteria, this Specific Noteworthy Ventricular Tachycardias
algorithm is applied stepwise, stopping if VT is ever suggested, and Three types of VT (right or left ventricular outflow tract VT, and
ending with SVT if no criteria suggests VT. The original algorithm was fascicular VT) are particularly amenable to treatment by drugs,
modified in a subsequent paper for increased ease of use13 though other catheter ablation or both. These largely benign forms of VT are
authors have noted that the application of the ventricular activation particularly important; their presence, in the setting of a structurally
velocity ratio (Vi/Vt) criteria (needed in up to 50 % of cases) can be normal heart, is a contraindication for ICD implantation.21 Diagnosis
frustrating and imprecise at standard ECG scales and paper speeds.16 of these forms of VT is more difficult than the VT-related to structural
Thus, the accuracy of the algorithm, 92 % in the original paper, was far heart disease, because the QRS duration is comparatively shorter, VA
less in a subsequent large study (72 %). The Vereckei (2008) criteria are: conduction is often present (not dissociated), and many other criteria
fail to distinguish these VTs from SVT (as in Figure 4). An additional
• Step 1: An initial, dominant R in aVR = VT. VT-type, bundle branch re-entry (BBR), usually has an appearance
• Step 2: An initial, non-dominant q or r in aVR >40 ms = VT. indistinguishable from LBBB SVT (propagation anterogradely over RBB,
• Step 3: Notching on an initial downstroke in aVR = VT. retrogradely over LBB) and thus belongs in the general category of
• Step 4: Vt≥Vi in aVR = VT. To apply, measure the total vertical VTs that are difficult (if not impossible) to distinguish from SVT. While
distance covered by the final 40 ms of the QRS in aVR. If this BBR VT is also quite amenable to catheter ablation, it generally occurs
is equal to or more than the vertical distance covered by the in patients with significant structural heart disease (cardiomyopathy);
first 40 ms of the aVR QRS, VT is diagnosed. The concept is that thus most patients with BBR VT also warrant ICD therapy.
with aberration, ventricular activation during the first portion of
the QRS is mediated by the His-Purkinje system, whereas in VT, Remaining Problems
the His-Purkinje system is engaged later in the QRS complex. Though published criteria to diagnose WCTs demonstrate
admirable test characteristics in their initial reports, clinicians still have
The Pava Criteria of Lead II difficulty arriving at the correct diagnosis. Potential causes for this are
In 2010, Pava et al. published the second algorithm offering diagnosis many, including:
from a single lead, without regard to BBB morphology, and this time
using only a single relatively simple measurement.19 • complexity of differentiation criteria;
• unfamiliarity with the criteria;
This is the R wave peak time in lead II, with the interval from QRS onset • incorrect application of criteria (i.e. misreading a QRS duration);
to first change in polarity (R or S peak) in lead 2 ≥50 ms denoting VT. and
• disbelieving the results of applying the criteria (“I know everything
The original paper reported remarkable test characteristics with an area points to VT, but he looks so good that it must be SVT”).
under receiver operator curve exceeding 98 %, specificity of 99 % and
PPV of 98 %, meaning the algorithm promised to distinguish VT from Certainly, the very simplified criteria set forth by Vereckei and Pava in
SVT with 94.5 % accuracy from a single measurement. The algorithm’s recent years go a long way toward rectifying the first two obstacles to
performance was substantially less favourable in its first large external correct diagnosis, but remedies for the other shortcomings may not
application, with an overall accuracy of just 69.0 % compared to, for be as readily forthcoming.
example, the Brugada criteria (77.5 % accurate) in that same study.16
Further study is needed to determine the true value of this criterion. Conclusion
Application of many of the foregoing criteria is shown in Figures 2-5). The diagnosis of VT has undergone evolution and development in
concert with the field of cardiology itself, but the necessity of a correct
A Different Approach – The Griffith Algorithm diagnosis remains unchanged. The world has not yet seen the ‘one
Recognising the high prevalence of VT and the limited number of typical criterion to end all criteria’, and it seems unlikely to appear in our
aberrancies allowed by the conduction system, Griffith et al. proposed near future. Until that time, maintaining familiarity with several of the
criteria, which function in a manner counter to the algorithms above – available criteria will assist any provider in delivering the proper care
each ECG is analysed for V1 and V6 criteria consistent with aberration.20 when it is needed most. When all else fails, it is wisest to treat the
If the criteria for aberration are not found, VT is assumed. As the patient initially as though the diagnosis was VT (which, as noted, is
algorithm defaults to VT, its sensitivity can be excellent, but specificity correct about 80 % of the time) and leave the fine-tuning of diagnosis
(and therefore overall accuracy as well) suffer, both in the original paper and long-term management plan for later. n

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