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'''''[[Sandbox 1 mobile|For the mobile version, click here]]'''''
'''''[[Sandbox 1 mobile|For the mobile version, click here]]'''''
{{SK}} WCT; fast and wide; wide and fast; wide-complex tachycardia; wide complex rhythm; SVT with aberrancy; SVT with aberrant conduction; supraventricular tachycardia with aberrancy; VT versus SVT; broad complex tachycardia


==Overview==
==Overview==
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* [[Ventricular tachycardia]]
* [[Ventricular tachycardia]]


==Diagnosis==
Click '''[[Wide complex tachycardia|here]]''' for the complete list of causes.
 
==FIRE: Focused Initial Rapid Evaluation==
The aim of FIRE is to identify urgent conditions that require immediate intervention in suspected [[narrow complex tachycardia]] based on the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Part 7.3: Management of Symptomatic Bradycardia and Tachycardia | url = http://circ.ahajournals.org/content/112/24_suppl/IV-67.full | publisher =  | date =  | accessdate = 2 March 2014 }}</ref>
 
<span style="font-size:85%">Boxes in red signify that an urgent management is needed.</span>


Shown below is an algorithm depicting the diagnostic approach to wide complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Part 7.3: Management of Symptomatic Bradycardia and Tachycardia | url = http://circ.ahajournals.org/content/112/24_suppl/IV-67.full | publisher =  | date =  | accessdate = 2 March 2014 }}</ref>
==Complete Diagnostic Approach==
Shown below is an algorithm depicting the complete diagnostic approach to [[wide complex tachycardia]] according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.<ref name="pmid14563598">{{cite journal| author=Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ et al.| title=ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2003 | volume= 42 | issue= 8 | pages= 1493-531 | pmid=14563598 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14563598  }} </ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Part 7.3: Management of Symptomatic Bradycardia and Tachycardia | url = http://circ.ahajournals.org/content/112/24_suppl/IV-67.full | publisher =  | date =  | accessdate = 2 March 2014 }}</ref>


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Revision as of 20:32, 4 April 2014

Wide Complex Tachycardia Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

For the mobile version, click here

Synonyms and keywords: WCT; fast and wide; wide and fast; wide-complex tachycardia; wide complex rhythm; SVT with aberrancy; SVT with aberrant conduction; supraventricular tachycardia with aberrancy; VT versus SVT; broad complex tachycardia

Overview

Wide complex tachycardia is characterized by a heart rate more than 100 beats per minute associated with a QRS interval of more than 120 ms. When wide complex tachycardia is present, it is important to determine whether the tachycardia is of a supraventricular or a ventricular origin.[1]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Wide complex tachycardia may be a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

The aim of FIRE is to identify urgent conditions that require immediate intervention in suspected narrow complex tachycardia based on the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1][2]

Boxes in red signify that an urgent management is needed.

Complete Diagnostic Approach

Shown below is an algorithm depicting the complete diagnostic approach to wide complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1][2]

Click on boxes to expand/collapse detailed information.


Characterize the symptoms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Characterize the timing of the symptoms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Identify possible triggers

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Examine the patient
❑ Order an EKG

 
 
 
 
 
 
 
 
 
 

Characterize the symptoms

❑ Asymptomatic
Palpitations
Dyspnea
Fatigue
Chest discomfort
Lightheadedness
Syncope

Characterize the timing of the symptoms

❑ Onset
❑ Duration
❑ Frequency

Treatment

Shown below is an algorithm depicting the therapeutic approach of wide complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias and the 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.[1][2]

ABC: Air, breathing and circulation; Afib: Atrial fibrillation; BBB: Bundle branch block; LV: Left ventricle; SVT: Supraventricular tachycardia; VT: Ventricular tachycardia; WPW: Wold Parkinson White

Click on boxes to expand/collapse detailed information.


 
 
 
 
 
 
 
 
 
 

Wide complex tachycardia
QRS ≥ 120ms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Begin initial management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Determine if the patient has any unstable sign or symptom

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

No

 
 
 
 
 
 
 

Yes

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Determine the regularity of the rhythm

 
 
 
 
 
 
 

Perform immediate synchronized cardioversion

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Regular rhythm

 
 
 
 
 
 
 

Irregular rhythm

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

VT or uncertain rhythm

 

SVT with aberrancy

 

Afib with aberrancy

 

Pre-excited Afib (Afib + WPW)

 

Recurrent polymorphic VT

 

Torsade de pointes

Begin initial management

❑ Assess and support ABC's as needed
❑ Give oxygen
❑ Monitor ECG, blood pressure, oxymetry
❑ Establish IV access
❑ Identify and treat reversible causes

Determine if the patient has any unstable sign or symptom

Chest pain
Congestive heart failure
Hypotension
Loss of consciousness
Seizures


Perform immediate synchronized cardioversion

❑ Perform immediate synchronized cardioversion
❑ Give IV sedation if the patient is conscious
❑ Consider expert consultation

VT or uncertain rhythm

❑ Give amiodarone 150 mg IV over 10 min
❑ Repeat amiodarone as needed for a maximal dose of 2.2g/24h
❑ Prepare for elective synchronized cardioversion

SVT with aberrancy

❑ Attempt vagal maneuvers
❑ Give adenosine 6 mg rapid IV push
❑ If no conversion give 12 mg IV push
❑ May repeat 12 mg dose once

Afib with aberrancy

❑ Consider expert consultation
❑ Control rate e.g diltiazem or beta blockers

Pre-excited Afib (Afib + WPW)

❑ Consider expert consultation
❑ Avoid AV nodal blocking agents e.g adenosine, digoxin, diltiazem and verapamil
❑ Consider amiodarone 150 mg IV over 10 min

Recurrent polymorphic VT

❑ Consider expert consultation

Torsade de pointes

❑ Load with magnesium 1-2 g over 5-60 min, then infusion

Differentiating SVT from VT

Shown below is a table summarizing some clues that help differentiate SVT from VT.[1]

Clues Type of arrhythmia
Irregularly irregular rhythm Atrial fibrillation or atrial flutter with aberrancy
Previous myocardial infarction or structural heart disease Ventricular tachycardia
Ventricular rate faster than atrial rate Ventricular tachycardia
Typical RBBB or LBBB Supraventricular tachycardia
Precordial leads:
❑ Concordant
❑ No R/S pattern
❑ Onset of R to nadir longer than 100ms
Ventricular tachycardia
RBBB pattern:
❑ qR, Rs or Rr' in V1
❑ Frontal plane axis range from +90 degrees to -90 degrees
Ventricular tachycardia
LBBB pattern:
❑ R in V1 longer than 30 ms
❑ R to nadir of S in V1 greater than 60 ms
❑ qR or qS in V6
Ventricular tachycardia

For more details about differentiating VT from SVT, click here

Antiarrhythmics

Shown below is a table summarizing the choices of the antiarrhythmic drugs for the different types of tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[1]

BBB: Bundle branch block; LV: Left ventricle; SVT: Supraventricular tachycardia

Management of wide complex tachycardia
Ventricular tachycardia or wide QRS tachycardia of unknown origin
Procainamide (Class I, level of evidence B)
OR
Sotalol (Class I, level of evidence B)
OR
Amiodarone
OR
Cardioversion (Class I, level of evidence B)
OR
Lidocaine (Class IIb, level of evidence B)
OR
Adenosine (Class IIb, level of evidence C)
OR
Beta blocker (Class III, level of evidence C)
OR
Verapamil (Class III, level of evidence B)
Wide QRS tachycardia of unknown origin + poor LV function
Amiodarone (Class I, level of evidence B)
OR
Cardioversion (Class I, level of evidence B)
SVT + BBB
Vagal maneuvers (Class I, level of evidence B)
OR
Adenosine (Class I, level of evidence A)
OR
Verapamil (Class I, level of evidence A)
OR
Diltiazem (Class I, level of evidence A)
OR
Beta blocker (Class IIb, level of evidence C)
OR
Amiodarone (Class IIb, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
SVT or atrial fibrillation + Preexcitation
Flecainide (Class I, level of evidence B)
OR
Ibutilide (Class I, level of evidence B)
OR
Procainamide (Class I, level of evidence B)
OR
Cardioversion (Class I, level of evidence C)

Do's

Dont's

  • Don't rely on the hemodynamic status of the patient and the heart rate to differenciate SVT from VT.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ; et al. (2003). "ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society". J Am Coll Cardiol. 42 (8): 1493–531. PMID 14563598.
  2. 2.0 2.1 2.2 "Part 7.3: Management of Symptomatic Bradycardia and Tachycardia". Retrieved 2 March 2014.

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