Value of preexisting bundle branch block in the electrocardiographic differentiation of supraventricular from ventricular origin of wide QRS tachycardia

doi:10.1016/0002-9149(85)90143-2

The American Journal of Cardiology

Volume 55, Issue 6, 1 March 1985, Pages 717-721

https://doi.org/10.1016/0002-9149(85)90143-2 Get rights and content

Abstract

The relation between the morphologic configuration of QRS complexes during wide QRS tachycardia induced during electrophysiologic studies and sinus rhythm was examined in 18 patients who had preexisting left or right bundle branch block. Representative QRS complexes during sinus rhythm and during tachycardia were isolated from each patient and juxtaposed for comparison. The QRS complexes that constituted each pair were judged by 4 observers as being identical, different or, if the decision was equivocal, similar. Nine patients had supraventricular tachycardia (SVT). In 8 of the 9 patients, all 4 observers found the QRS complexes during sinus rhythm and SVT identical in morphologic configuration. In the other patient, 2 observers found the QRS complexes identical and 2 found them similar. In 12 patients ventricular tachycardia (VT) was induced. In 11 of these 12, all 4 observers found the QRS complexes during VT different from their respective sinus beats. In the other patient, 3 observers found the QRS complexes different, whereas the fourth found them similar. During SVT, the QRS duration was unchanged from the corresponding value during sinus rhythm, whereas in patients with VT, QRS width increased by a mean of 56 ± 20 ms (p < 0.001). The results of our study suggest that the electrocardiographic differentiation of wide QRS tachycardia in patients with preexisting bundle branch block can be accomplished easily and accurately by comparing the QRS complexes during tachycardia with those during sinus rhythm: If the complexes are identical, the tachycardia is supraventricular, but if they are different, the arrhythmia is ventricular in origin.

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Cited by (51)

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Though their seminal observations were narrowly focused on defining the origin of isolated wide complex beats with right BBB morphology, their work is recognized as delivering one of the earliest means to differentiate WCTs by way of baseline ECG comparison. Later, in 1985, Dongas and colleagues [8] examined the diagnostic value of comparing QRS morphology, QRS axis, and QRS duration between the WCT and baseline ECGs with preexisting BBB. In their report, WCTs with unchanged QRS morphologies (at leads V1, II, and III) compared to the preexisting BBB in sinus rhythm were almost invariably SWCT, while WCTs with different QRS morphologies were likely VT.
Accurate wide QRS complex tachycardia (WCT) differentiation into either ventricular tachycardia or supraventricular wide complex tachycardia using 12‑lead electrocardiogram (ECG) interpretation is essential for diagnostic, therapeutic, and prognostic reasons. There is an ever-expanding variety of WCT differentiation methods and criteria available to clinicians. However, only a few make use of the diagnostic value of comparing the ECG during WCT to that of the patient's baseline ECG. Therefore, we highlight the conceptual rationale and scientific literature supporting the diagnostic value of WCT and baseline ECG comparison.
Specificity of electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardia in patients with intraventricular conduction defect
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Possible electrophysiological explanations for the appearance of changes in QRS morphology were discussed in more detail elsewhere.4 In summary, it is worth mentioning that the criterion established by Dongas et al10 suggesting the absence of changes in QRS morphology was based on the concept that in the presence of the complete BBB ECG pattern, conduction through the affected bundle branch is prevented and so all supraventricular beats (including sinus) would conduct exclusively through the contralateral bundle. Nevertheless, the “complete” BBB pattern may appear with a mere slowing in conduction in a bundle branch and classical studies using an atrial extrastimulus technique confirmed this finding.11,12
In patients with organic intraventricular conduction defects (IVCDs), (1) QRS morphology during sinus rhythm frequently meets ventricular tachycardia (VT) morphological criteria and (2) there are further rate-related changes in QRS morphology.
To search for the best morphological criteria in this context.
We prospectively studied 69 patients, in sinus rhythm, with QRS duration ≥120 ms. Continuous rapid atrial pacing (RAP) trains were introduced at increasing rates in order to mimic supraventricular tachycardia. We analyzed the specificity of VT criteria during RAP. Finally, we used the criteria with a specificity of ≥0.9 in a “test sample” of 53 patients with preexisting IVCD and wide complex tachycardia to confirm their validity.
Only 10 of the 20 analyzed criteria had a specificity of ≥0.9 during RAP at the highest rate. The specificity of these 10 criteria was confirmed in the test sample. The best accuracy to diagnose VT was obtained: for an isolated criterion: “R-wave peak time (RWPT) ≥50 ms at lead II” (specificity = 0.97; sensitivity = 0.67); for an algorithm: the combination of 2 criteria “RWPT ≥50 ms at lead II” and “absence of RS patterns in precordial leads” (specificity = 0.97; sensitivity = 0.88).
In patients with IVCD, (1) specificity of most VT criteria is low during RAP, suggesting a limited applicability of many of these criteria in case they develop supraventricular tachycardia, and (2) the superior accuracy to diagnose VT was observed with “RWPT ≥50 ms at lead II” and for an algorithm with the combination of “RWPT ≥50 ms at lead II” and “absence of RS patterns in precordial leads.”
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2006, Cardiology Clinics
Citation Excerpt :
The preceding criteria can be applied when only the WQRST ECG is available; as health information systems become more integrated, it should be possible to readily access a WQRST patient's prior ECGs for comparison. In such cases, the following additional criteria can be applied [2,5]: Identical QRS configuration between baseline and WQRST [2,12,13].
Tachydysrhythmias
2006, Emergency Medicine Clinics of North America
Citation Excerpt :
In patients who have a positive QRS complex in V1, an RSR′ morphology and an Rs wave in V6 with R wave height greater than S wave depth are highly supportive of a pre-existing RBBB. In patients who have suspected SVT with LBBB morphology, the presence of an rS or QS wave in leads V1 and V2, delay to S wave nadir of <0.07 seconds, and R wave without preceding Q wave in lead V6 is diagnostic of LBBB (Fig. 12) [11–15]. There is a rate-related bundle branch delay or block.
Differential Diagnosis of Wide QRS Complex Tachycardia
2004, Cardiac Electrophysiology: Fourth Edition
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Value of preexisting bundle branch block in the electrocardiographic differentiation of supraventricular from ventricular origin of wide QRS tachycardia

Abstract

Prog Cardiovasc Dis

Prog Cardiovasc Dis

Am J Med

Am Heart J

The differential morphology of anomalous ventricular complexes of RBBB type in lead V1: ventricular ectopy versus aberration

Circulation

Value and limitations of programmed electrical stimulation of the heart in the study and treatment of tachycardias

Circulation

The differentiation between ventricular tachycardia and supraventricular tachycardia with aberrant conduction: the value of the electrocardiogram

The differential morphology of anomalous ventricular complexes of RBBB type in lead V₁: ventricular ectopy versus aberration