Advertisement

Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm

Published:September 20, 2019DOI:https://doi.org/10.1016/j.hrthm.2019.09.021

      Background

      The electrocardiogram (ECG) is essential for the differential diagnosis of wide QRS complex tachycardia (WCT).

      Objective

      The purpose of this study was to evaluate the diagnostic value of a novel ECG algorithm on the basis of the morphological characteristics of the QRS on the limb leads.

      Methods

      The limb lead algorithm (LLA) was evaluated by analyzing 528 monomorphic WCTs with electrophysiology-confirmed diagnoses. In the LLA, ventricular tachycardia (VT) is diagnosed in the presence of at least 1 of the following: (1) monophasic R wave in lead aVR; (2) predominantly negative QRS in leads I, II, and III; and (3) opposing QRS complex in the limb leads: concordant monophasic QRS in all 3 inferior leads and concordant monophasic QRS in 2 or 3 of the remaining limb leads with a polarity opposite to that of the inferior leads. The diagnostic performance of the LLA was compared with that of the Brugada, Vereckei, and R-wave peak time (RWPT) algorithms.

      Results

      Of 528 WCT cases, 397 were VT and 131 supraventricular tachycardia. The interobserver agreement for the LLA was excellent (κ = 0.98), better than that for the other algorithms. The overall accuracy of the LLA (88.1%) was similar to that of Brugada (85.4%) and Vereckei (88.1%) algorithms but was higher than that of the RWPT algorithm (70.8%). The LLA had a lower sensitivity (87.2%) than did Brugada (94.0%) and Vereckei (92.4%) algorithms, but not the RWPT algorithm (67.8%). Furthermore, the LLA showed a higher specificity (90.8%) than did Brugada (59.5%), Vereckei (76.3%), and RWPT (80.2%) algorithms.

      Conclusion

      The LLA is a simple yet accurate method to diagnose VT when approaching WCTs on the ECG.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Al-Khatib S.M.
        • Stevenson W.G.
        • Ackerman M.J.
        • et al.
        2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
        Heart Rhythm. 2018; 15: e190-e252
        • Kaiser E.
        • Darrieux F.C.
        • Barbosa S.A.
        • et al.
        Differential diagnosis of wide QRS tachycardias: comparison of two electrocardiographic algorithms.
        Europace. 2015; 17: 1422-1427
        • Wellens H.J.
        • Bar F.W.
        • Lie K.I.
        The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
        Am J Med. 1978; 64: 27-33
        • Kindwall K.E.
        • Brown J.
        • Josephson M.E.
        Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias.
        Am J Cardiol. 1988; 61: 1279-1283
        • Brugada P.
        • Brugada J.
        • Mont L.
        • Smeets J.
        • Andries E.W.
        A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex.
        Circulation. 1991; 83: 1649-1659
        • Vereckei A.
        • Duray G.
        • Szenasi G.
        • Altemose G.T.
        • Miller J.M.
        New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia.
        Heart Rhythm. 2008; 5: 89-98
        • Pava L.F.
        • Perafan P.
        • Badiel M.
        • et al.
        R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias.
        Heart Rhythm. 2010; 7: 922-926
        • Jastrzebski M.
        • Kukla P.
        • Czarnecka D.
        • Kawecka-Jaszcz K.
        Comparison of five electrocardiographic methods for differentiation of wide QRS-complex tachycardias.
        Europace. 2012; 14: 1165-1171
        • Szelenyi Z.
        • Duray G.
        • Katona G.
        • et al.
        Comparison of the “real-life” diagnostic value of two recently published electrocardiogram methods for the differential diagnosis of wide QRS complex tachycardias.
        Acad Emerg Med. 2013; 20: 1121-1130
        • Isenhour J.L.
        • Craig S.
        • Gibbs M.
        • Littmann L.
        • Rose G.
        • Risch R.
        Wide-complex tachycardia: continued evaluation of diagnostic criteria.
        Acad Emerg Med. 2000; 7: 769-773
        • Chen Q.
        • Mohanty S.
        • Rocca D.D.
        • et al.
        A new, simple ECG algorithm for the rapid identification of ventricular tachycardia based on opposing QRS complexes on limb leads.
        J Am Coll Cardiol. 2019; 73: 319
        • Yamada T.
        Transthoracic epicardial catheter ablation: indications, techniques, and complications.
        Circ J. 2013; 77: 1672-1680
        • Vereckei A.
        • Duray G.
        • Szenasi G.
        • Altemose G.T.
        • Miller J.M.
        Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia.
        Eur Heart J. 2007; 28: 589-600
        • Kashou A.H.
        • Kashou H.E.
        Electrical Axis (Normal, Right Axis Deviation, and Left Axis Deviation).
        StatPearls, Treasure Island, FL2018
        • Moskowitz C.S.
        • Pepe M.S.
        Comparing the predictive values of diagnostic tests: sample size and analysis for paired study designs.
        Clin Trials. 2006; 3: 272-279
        • Kamakura S.
        • Shimizu W.
        • Matsuo K.
        • et al.
        Localization of optimal ablation site of idiopathic ventricular tachycardia from right and left ventricular outflow tract by body surface ECG.
        Circulation. 1998; 98: 1525-1533
        • Tada H.
        • Tadokoro K.
        • Ito S.
        • et al.
        Idiopathic ventricular arrhythmias originating from the tricuspid annulus: prevalence, electrocardiographic characteristics, and results of radiofrequency catheter ablation.
        Heart Rhythm. 2007; 4: 7-16
        • Tada H.
        • Ito S.
        • Naito S.
        • et al.
        Idiopathic ventricular arrhythmia arising from the mitral annulus: a distinct subgroup of idiopathic ventricular arrhythmias.
        J Am Coll Cardiol. 2005; 45: 877-886
        • Della Rocca D.G.
        • Gianni C.
        • Mohanty S.
        • Trivedi C.
        • Di Biase L.
        • Natale A.
        Localization of ventricular arrhythmias for catheter ablation: the role of surface electrocardiogram.
        Card Electrophysiol Clin. 2018; 10: 333-354
        • Surawicz B.
        • Childers R.
        • Deal B.J.
        • et al.
        AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram. Part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology.
        J Am Coll Cardiol. 2009; 53: 976-981
        • Vereckei A.
        Current algorithms for the diagnosis of wide QRS complex tachycardias.
        Curr Cardiol Rev. 2014; 10: 262-276
        • Ceresnak S.R.
        • Liberman L.
        • Avasarala K.
        • Tanel R.
        • Motonaga K.S.
        • Dubin A.M.
        Are wide complex tachycardia algorithms applicable in children and patients with congenital heart disease?.
        J Electrocardiol. 2010; 43: 694-700
        • Lau E.W.
        • Ng G.A.
        Comparison of the performance of three diagnostic algorithms for regular broad complex tachycardia in practical application.
        Pacing Clin Electrophysiol. 2002; 25: 822-827
        • Jastrzebski M.
        • Kukla P.
        • Czarnecka D.
        • Kawecka-Jaszcz K.
        Specificity of the wide QRS complex tachycardia algorithms in recipients of cardiac resynchronization therapy.
        J Electrocardiol. 2012; 45: 319-326
        • Enriquez A.
        • Pathak R.K.
        • Santangeli P.
        • et al.
        Inferior lead discordance in ventricular arrhythmias: a specific marker for certain arrhythmia locations.
        J Cardiovasc Electrophysiol. 2017; 28: 1179-1186
        • Kligfield P.
        • Gettes L.S.
        • Bailey J.J.
        • et al.
        Recommendations for the standardization and interpretation of the electrocardiogram. Part I: the electrocardiogram and its technology a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society endorsed by the International Society for Computerized Electrocardiology.
        J Am Coll Cardiol. 2007; 49: 1109-1127