The ventricular tachycardia score: a novel approach to electrocardiographic diagnosis of ventricular tachycardia (original) (raw)
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Academic Emergency Medicine, 2013
Objectives: The diagnostic values of the aVR lead or "Vereckei algorithm," and the lead II R-wave peak time (RWPT) criterion, recently devised for the differential diagnosis of wide QRS complex tachycardias (WCTs), were compared. Methods: A total of 212 WCTs (142 ventricular tachycardias [VTs], 62 supraventricular tachycardias [SVT], and eight preexcitation SVTs) from 145 patients with proven electrophysiologic diagnoses were retrospectively analyzed by seven examiners blinded to the electrophysiologic diagnoses. Results: The overall test accuracy of the Vereckei algorithm was superior to that of the RWPT criterion (84.3% vs. 79.6%; p = 0.0003). The sensitivity of the Vereckei algorithm for VT diagnosis was greater than that of RWPT criterion (92.4% vs. 79.1%; p < 0.0001). The negative predictive value (NPV) for the Vereckei algorithm was also greater (77.8%; 95% confidence interval [CI] = 73.6% to 82.1%) than that of the RWPT criterion (61.6%; 95% CI = 57.6% to 65.6%). The specificity of the Vereckei algorithm was lower than that of the RWPT criterion (64.7% vs. 80.9%; p < 0.0001). The positive predictive value (PPV) was also lower for the Vereckei algorithm (86.4%; 95% CI = 84.4% to 88.4%) than for the RWPT criterion (90.9%; 95% CI = 89.1% to 92.8%). Incorrect diagnoses made by the Vereckei algorithm were mainly due to misdiagnosis of SVT as VT (65.7% of cases), and those made by the RWPT criterion were due to the more dangerous misdiagnosis of VT as SVT (72.5% of cases). Conclusions: The Vereckei algorithm was superior in overall test accuracy, sensitivity, and NPV for VT diagnosis and inferior in specificity and PPV to the RWPT criterion. All of these parameters were lower in "real life" than those reported by the original authors for each of the particular electrocardiographic methods.
Differential diagnosis of wide QRS tachycardias: comparison of two electrocardiographic algorithms
Europace, 2015
This study's aim is to compare the ability of two ECG criteria to differentiate ventricular (VT) from supraventricular tachycardia SVT): Brugada et al. [horizontal plane (HP) leads] and Vereckei et al. [frontal plane (FP), specifically aVR lead], having electrophysiological study (EPS) as gold standard. After comparing, suggestions for better diagnosis of wide QRS-complex tachycardia (WCT) in emergency situations were made.
Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia
European Heart Journal, 2006
Aims The Brugada criteria proposed to distinguish between regular, monomorphic wide QRS complex tachycardias (WCT) caused by supraventricular (SVT) and ventricular tachycardia (VT) have been reported to have a better sensitivity and specificity than the traditional criteria. By incorporating two new criteria, a new, simplified algorithm was devised and compared with the Brugada criteria. Methods and results A total of 453 WCTs (331 VTs, 105 SVTs, 17 pre-excited tachycardias) from 287 consecutive patients with a proven electrophysiological (EP) diagnosis were prospectively analysed by two of the authors blinded to the EP diagnosis. The following criteria were analysed: (i) presence of AV dissociation; (ii) presence of an initial R wave in lead aVR; (iii) whether the morphology of the WCT correspond to bundle branch or fascicular block; (iv) estimation of initial (v i ) and terminal (v t ) ventricular activation velocity ratio (v i /v t ) by measuring the voltage change on the ECG tracing during the initial 40 ms (v i ) and the terminal 40 ms (v t ) of the same bi-or multiphasic QRS complex. A v i /v t .1 was suggestive of SVT and a v i /v t 1 of VT. An initial R wave in lead aVR suggested VT. The overall test accuracy of the new algorithm was superior (P ¼ 0.006) to that of the Brugada criteria. The new algorithm had a greater sensitivity (P , 0.001) and (2) predictive value (NPV) for VT diagnosis, and specificity (P ¼ 0.0471) and (þ) predictive value (PPV) for SVT diagnosis than those of the Brugada criteria [both NPV for VT diagnosis and PPV for SVT diagnosis were: 83.5% (95% confidence interval ¼ CI 75.9-91.1%) for the new vs. 65.2% (95% CI 56.5-73.9%) for the Brugada algorithms]. Conclusion The new algorithm is a highly accurate tool for correctly diagnosing the cause of WCT ECGs.
New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia
Heart Rhythm, 2008
BACKGROUND We recently reported an ECG algorithm for differential diagnosis of regular wide QRS complex tachycardias that was superior to the Brugada algorithm. OBJECTIVE The purpose of this study was to further simplify the algorithm by omitting the complicated morphologic criteria and restricting the analysis to lead aVR. METHODS In this study, 483 wide QRS complex tachycardias [351 ventricular tachycardias (VTs), 112 supraventricular tachycardias (SVTs), 20 preexcited tachycardias] from 313 patients with proven diagnoses were prospectively analyzed by two of the authors blinded to the diagnosis. Lead aVR was analyzed for (1) presence of an initial R wave, (2) width of an initial r or q wave Ͼ40 ms, (3) notching on the initial downstroke of a predominantly negative QRS complex, and (4) ventricular activation-velocity ratio (v i /v t), the vertical excursion (in millivolts) recorded during the initial (v i) and terminal (v t) 40 ms of the QRS complex. When any of criteria 1 to 3 was present, VT was diagnosed; when absent, the next criterion was analyzed. In step 4, v i /v t Ͼ1 suggested SVT, and v i /v t Յ1 suggested VT. RESULTS The accuracy of the new aVR algorithm and our previous algorithm was superior to that of the Brugada algorithm (P ϭ .002 and P ϭ .007, respectively). The aVR algorithm and our previous algorithm had greater sensitivity (P Ͻ.001 and P ϭ .001, respectively) and negative predictive value for diagnosing VT and greater specificity (P Ͻ.001 and P ϭ .001, respectively) and positive predictive value for diagnosing SVT compared with the Brugada criteria. CONCLUSION The simplified aVR algorithm classified wide QRS complex tachycardias with the same accuracy as standard criteria and our previous algorithm and was superior to the Brugada algorithm. KEYWORDS Wide QRS complex tachycardia; Brugada criteria; Ventricular tachycardia; Supraventricular tachycardia
JACC: Clinical Electrophysiology, 2017
OBJECTIVES This study sought to determine the ability of conventional electrocardiographic (ECG) criteria to correctly differentiate idiopathic ventricular tachycardia (VT) from supraventricular tachycardia (SVT) with aberrancy. BACKGROUND Previously reported VT ECG criteria were developed from cohorts of patients with structural heart disease and have not been applied to patients with idiopathic VT. METHODS ECGs of 115 idiopathic VTs, 101 post-myocardial infarction (MI) VTs, and 111 wide QRS SVTs were analyzed using standard criteria. VT was diagnosed in patients when at least 1 criterion was met, SVT when no criteria were met, and indeterminate when there were conflicting criteria. RESULTS Standard ECG criteria more frequently diagnosed VT in the post-MI group than the idiopathic group (95% vs. 82%, respectively; p < 0.01). Diagnosis in only 12 of the 111 SVT patients (11%) met the criteria for VT. All patients in the idiopathic VT group with right branch bundle block morphology who did not meet VT criteria demonstrated an rsR 0 pattern in V 1 (consistent with SVT). Among idiopathic VT patients, Purkinje-associated VT had the lowest sensitivity for correct VT diagnosis in 13 of 23 patients (57%), septal sites of origin were correctly diagnosed in only 56 of 76 patients (74%), whereas nonseptal sites had a high sensitivity in 35 of 35 patients (100%; p < 0.005). CONCLUSIONS Conventional ECG criteria have reduced sensitivity to distinguish VT from SVT with aberrancy in patients with idiopathic VT. This is most pronounced in VT originating from septal sites, particularly Purkinje sites and the septal outflow tract regions. Clinicians should be aware that application of conventional ECG criteria in idiopathic VT may
Journal of Cardiology, 2012
Background: Accurate electrocardiographic (ECG) differentiation of ventricular tachycardia (VT) from supraventricular tachycardia with aberrancy (SVT-A) on ECG is key to therapeutic decision-making in the emergency department (ED) setting. Objective: The goal of this study was to test the accuracy and agreement of emergency medicine residents to differentiate VT from SVT-A using the Vereckei criteria. Methods: Six emergency medicine residents volunteered to participate in the review of 114 ECGs from 86 patients with a diagnosis of either VT or SVT-A based on an electrophysiology study. The resident reviewers initially read 12-lead ECGs blinded to clinical information, and then one week later reviewed a subset of the same 12-lead ECGs unblinded to clinical information.
ECG Criteria to Identify Epicardial Ventricular Tachycardia in Nonischemic Cardiomyopathy
Circulation-arrhythmia and Electrophysiology, 2010
a, Pe Pe e e e e enn nn nn nn nnsy sy sy sy sy sy sylv lv lv lv lv lv van an an an an an ania ia i ia ia ia ia.1 Abstract Background: ECG criteria identifying epicardial (EPI) origin for ventricular tachycardia (VT) in non-ischemic cardiomyopathy (NICM) have not been determined. Endocardial (ENDO) and EPI basal left ventricle fibrosis characterizes the VT substrate. Methods and Results: We assessed the QRS from 102 basal-superior/lateral EPI and 67 comparable ENDO pacemaps (PM) in 14 patients with NICM. Pacemapping focused on low bipolar voltage areas. Published morphology: q wave in lead I (QWL1), no q waves in inferior leads and interval criteria: pseudo-delta wave (PdW) 34ms, intrinsicoid deflection time 85ms, shortest RS complex 121ms and maximum deflection index (MDI) 0.55 were assessed for ability to identify EPI origin. Sixteen EPI and 8 ENDO of the 34 mapped VTs (71%) in the study population and 14 EPI and 7 ENDO VTs from an 11 patient validation cohort were localized to basal-superior/lateral left ventricle and corroborated pacing data. A QWL1 was seen in EPI but not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 EPI VTs (sensitivity 88%) and was seen in 1/8 ENDO VT's (specificity 88%). None of the remaining criteria achieved similar sensitivity without specificity <50%. We identified 4 criteria (q waves in inferior leads, PdW 75 ms, MDI 0.59 and QWL1) having 95% specificity and 20% sensitivity in identifying EPI/ENDO origin for PMs. This four-step algorithm identified the origin in 109/115 PMs (95%), 21/24 VTs (88%) in study population and 19/21 VTs (90%) in validation cohort. Conclusion: Morphologic ECG features that describe the initial QRS vector can help identify basal-superior/lateral EPI VTs in NICM. or or or or or or or a a a a a a abi bi bi bi bi bi bili li li li li li lity ty ty ty ty ty ty t t t t t t to o o o o o o id id id id id id ide e e e e e e %) in n n n n n n t t t t t t the he he he he he he s s s s s s stu tu tu tu tu tu tudy dy dy dy dy dy dy p a c o not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 8 o it i hi d i il iti it ith t ifi it <5 and 7 ENDO VTs from an 11 patient validation cohort were loc or/lateral left ventricle and corroborated pacing data. A QWL1 not ENDO PMs (91% vs 4%; p<0.001), identified 14/16 88%) and was seen in 1/8 ENDO VT's (specificity 88%). No it i hi d i il iti it ith t ifi it <5 by guest on October 3, 2016 http://circep.ahajournals.org/ Downloaded from Fourteen patients with NICM undergoing ENDO and EPI catheter mapping and ablation for drug refractory ventricular arrhythmias were included in the study.