Wide complex tachycardia resident survival guide

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

Definition

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.

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

• Atrial fibrillation with aberrancy
• Atrial fibrillation with pre-excitation
• Supraventricular tachycardia (SVT) with aberrancy
• Ventricular tachycardia

Management

Shown below is an algorithm depicting the management 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.

Characterize the symptoms: ❑ Asymptomatic ❑ Palpitations ❑ Dyspnea ❑ Fatigue ❑ Chest discomfort ❑ Lightheadedness ❑ Syncope Characterize the timing of the symptoms: ❑ Onset ❑ Duration ❑ Frequency

Identify possible triggers: ❑ Infection ❑ Caffeine ❑ Alcohol ❑ Nicotine ❑ Recreational drugs ❑ Hypovolemia ❑ Hyperthyroidism ❑ Hypoxia ❑ Acidosis ❑ Hypokalemia ❑ Hyperkalemia ❑ Hypoglycemia ❑ Hypothermia ❑ Toxins ❑ Cardiac tamponade ❑ Pumonary embolism ❑ Coronary thrombosis ❑ Trauma

❑ Examine the patient ❑ Order an EKG

Wide complex tachycardia QRS ≥ 120ms

Do the following simultaneously: ❑ 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 of the following: ❑ Chest pain ❑ Congestive heart failure ❑ Hypotension ❑ Loss of consciousness ❑ Seizures

No

Yes

❑ Determine the regularity of the rhythm

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

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?

❑ 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

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

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

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

❑ Consider expert consultation

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

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

Differentiating SVT from VT

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

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.

Management of wide complex tachycardia 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) 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)

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

Do's

• Refer the patient to an arrhythmia specialist when the tachycardia causes syncope or dyspnea as well as when the wide complex tachycardia is of unknown cause.
• Place an ambulatory 24 hour Holter when the tachycardia is frequent and transient.
• Treat the patient as having a ventricular tachycardia when the diagnosis of supraventricular tachycardia can not be made.
• Suspect ventricular tachycardia in a patient with wide complex tachycardia and previous myocardial infarction or a history of structural heart disease.
• Use beta blockers with caution in pulmonary diseases or congestive heart failure.

Dont's

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