ECG CRITERIA SVT Vs VT

DR.VINOTH KUMAR
PostGraduate
VT DEFINITION

 Three or more consecutive ventricular ectopic beats in succession

 At a rate of 70 to 250 bpm

 Non sustained- terminated by self < 30 secs

 Sustained - Presence > 30 secs
hemodynamically unstable <30 secs

 Slow VT – 100-120 bpm

 Pulseless VT- hemodynamic collapse requiring DC
 Refractory VT- not reverted to sinus rhythm on medication or 3 DC shocks
 VT strom / Electrical strom - occurrence of three or more episodes of VT or
ventricular fibrillation (VF) within 24 h.
Specific characteristics of VT
 Very broad complexes (>160ms).

 Absence of typical RBBB or LBBB morphology.

 Extreme axis deviation (“northwest axis”) — QRS is positive in aVR and

negative in I + aVF.

 AV dissociation (P and QRS complexes at different rates)

 Capture beats — occur when the sinoatrial node transiently ‘captures’ the
ventricles, in the midst of AV dissociation, to produce a QRS complex of
normal duration.
 Fusion beats — occur when a sinus and ventricular beat coincide to
produce a hybrid complex of intermediate morphology.
 Positive or negative concordance throughout the chest leads
leads V1-6 show entirely positive (R) or
entirely negative (QS) complexes, with no RS complexes seen.
 Brugada’s sign – The distance from the onset of the QRS complex to the
nadir of the S-wave is > 100ms.
 Josephson’s sign – Notching near the nadir of the S-wave
 RSR’ complexes with a taller “left rabbit ear”. 
 This is the most specific finding in favour of VT.
 This in contrast to RBBB, where the right rabbit ear is taller
SVT Aberrancy Vs VT
SITE
 Journal of the American College of Cardiology
 Volume 54, Issue 13, September 2009DOI: 10.1016/j.jacc.2009.03.086
VENTRICULAR FLUTTER AND VF
 SUPRAVENTRICULAR RHYTHM DISTURBANCES,
 Sinus Tachycardia,
 Premature Atrial Complexes,
 Atrial Fibrillation,
 Atrial Tachycardias,
 Tachycardias Involving the Atrioventricular
 Junction,
 Other Forms of Tachycardia in Patients with
 Wolff-Parkinson-White Syndrome,
Sinus Tachycardia
 sinus node exhibits a discharge frequency between 100 and 180
beats/minute,

 it can also be higher with extreme exertion and in young individuals.

The maximum heart rate achieved during strenuous physical activity varies
widely but decreases with age

 The P-P interval can vary slightly from cycle to cycle, especially at slower
rates.

 P waves have a normal contour,

a larger amplitude can develop, and the wave can become peaked.

 They appear before each QRS complex with a stable PR interval

unless concomitant AV block .
 Accelerated phase 4 diastolic depolarization of sinus nodal cells
responsible for sinus tachycardia, caused by
elevated adrenergic tone or withdrawal of parasympathetic tone.

 Carotid sinus massage and Valsalva or other vagal maneuvers gradually

slow sinus tachycardia, which accelerates to its previous rate on
cessation of the enhanced vagal tone.

 More rapid sinus rates can fail to slow in response to a vagal maneuver,
particularly those driven by high adrenergic tone.
Chronic inappropriate sinus tachycardia( syndrome of inappropriate sinus
tachycardia) has been described in otherwise healthy persons,

 secondary to increased automaticity of the sinus node or an automatic atrial

focus near the sinus node.

 The abnormality can result from a defect in either sympathetic or vagal

nerve control of sinoatrial (SA) automaticity or from an abnormality of the
intrinsic heart rate.

In postural orthostatic tachycardia syndrome, a related syndrome consisting

of orthostatic hypotension and sinus tachycardia,

Both syndromes can result from autonomic neuropathy (either peripheral, as

in diabetic patients, or central, from spinal cord injury).
WPW - AVRT
 Pre-excitation refers to early activation of the ventricles due to impulses
bypassing the AV node via an accessory pathway.

 abnormal conduction pathways formed during cardiac development

exist in a variety of anatomical locations

 An AP can conduct impulses either 

anterograde, towards the ventricle, 
retrograde, away from the ventricle, or in both directions.
 In WPW the accessory pathway is often referred to as the Bundle of Kent,
or atrioventricular bypass tract.

 The majority of pathways allow conduction in

both directions,
with retrograde only conduction occurring in 15% of cases, and
anterograde only conduction rarely seen.

 Tachyarrythmia can be facilitated by the formation of a reentry circuit

involving the accessory pathway, termed atrioventricular reentry
tachycardias (AVRT)
 The features of pre-excitation may be subtle, or present only intermittently.

 Pre-excitation may be more pronounced with increased vagal tone e.g.

during Valsalva manoeuvres, or with AV blockade e.g. drug therapy.

 WPW may be described as type A or B.

Type A: positive delta wave in all precordial leads with R/S > 1 in V1
Type B: negative delta wave in leads V1 and V2
 In patients with retrograde-only accessory conduction all antegrade
conduction occurs via the AV node,
no features of WPW are seen on ECG in sinus rhythm (as no pre-
excitation
occurs). This is termed a “concealed pathway”.
 Patients with a concealed pathway can experience tachyarrythmias as the
pathway can still form part of a re-entry circuit
AVRT
 AVRT is a form of paroxysmal supraventricular tachycardia.

 reentry circuit is formed by the normal conduction system and the

accessory pathway resulting in circus movement.

 During tachyarrythmias the features of pre-excitation are lost as the

accessory pathway forms part of the reentry circuit.

 AVRT often triggered by premature atrial or premature ventricular beats.

 AVRT are further divided in to orthodromic or antidromic conduction

based on direction of reentry conduction
 AVRT with Orthodromic Conduction
 ECG features of AVRT with orthodromic conduction are:
 Rate 200 – 300 bpm
 P waves may be buried in QRS complex or retrograde
 QRS Complex usually <120 ms unless pre-existing bundle branch block, or
rate-related aberrant conduction
 QRS Alternans – phasic variation in QRS amplitude associated with
AVNRT and AVRT, distinguished from electrical alterans by a normal
QRS amplitude
 T wave inversion common
 ST segment depression
 AVRT with Antidromic Conduction
 antidromic AVRT anterograde conduction occurs via the AP with
retrograde
conduction via the AV node. Much less common than orthodromic AVRT
occurring in ~5% of patients with WPW.

 ECG features of AVRT with antidromic conduction are:

 Rate 200 – 300 bpm.
 Wide QRS complexes due to abnormal ventricular depolarisation via
accessory pathway.
AVNRT

 Electrocardiographic Features
 General Features of AVNRT
 Regular tachycardia ~140-280 bpm.
 QRS complexes usually narrow (< 120 ms) unless pre-existing bundle
branch block, accessory pathway, or rate related aberrant conduction.
 ST-segment depression may be seen with or without underlying coronary
artery disease.
 QRS alternans – phasic variation in QRS amplitude associated with AVNRT
and AVRT, distinguished from electrical alternans by a normal QRS
amplitude.
 P waves if visible exhibit retrograde conduction with P-wave inversion in
leads II, III, aVF.
 P waves may be buried in the QRS complex, visible after the QRS complex,
or very rarely visible before the QRS complex.
 Subtypes of AVNRT
 Different subtypes vary in terms of the dominant pathway and
the R-P interval. The RP interval represents the time between anterograde
ventricular activation (R wave) and retrograde atrial activation (P wave).

 Slow-Fast AVNRT (common type)

 Fast-Slow AVNRT (Uncommon AVNRT)

 Slow-Slow AVNRT (Atypical AVNRT)

 1. Slow-Fast AVNRT (common type)
 Accounts for 80-90% of AVNRT
 Associated with Slow AV nodal pathway for anterograde conduction and
Fast AV nodal pathway for retrograde conduction.
 The retrograde P wave is obscured in the corresponding QRS or occurs at
the end of the QRS complex as pseudo r’ or S waves
 ECG features:
 P waves are often hidden – being embedded in the QRS complexes.
 Pseudo R’ wave may be seen in V1 or V2.
 Pseudo S waves may be seen in leads II, III or aVF.
 In most cases this results in a ‘typical’ SVT appearance with absent P waves
and tachycardia
 2. Fast-Slow AVNRT (Uncommon AVNRT)
 Accounts for 10% of AVNRT

 Associated with Fast AV nodal pathway for anterograde conduction and

Slow AV nodal pathway for retrograde conduction.

 Due to the relatively long ventriculo-atrial interval, the retrograde P wave is

more likely to be visible after the corresponding QRS.

 ECG features:
 QRS-P-T complexes.
 Retrograde P waves are visible between the QRS and T wave
 3. Slow-Slow AVNRT (Atypical AVNRT)
 1-5% AVNRT
 Associated with Slow AV nodal pathway for anterograde conduction and
Slow left atrial fibres as the pathway for retrograde conduction.
 ECG features:
 Tachycardia with a P-wave seen appearing “before” the QRS complex.
 Confusing as a P wave appearing before the QRS complex in the face of a
tachycardia might be read as a sinus tachycardia.
 Summary of AVNRT subtypes
 No visible P waves? –> Slow-Fast
 P waves visible after the QRS complexes? –> Fast-Slow
 P waves visible before the QRS complexes? –> Slow-Slow