Wide-complex tachycardia: Difference between revisions

Latest revision as of 16:53, 30 July 2025

Background

3 wide complexes in a row is considered ventricular tachycardia
- Non-sustained if lasts < 30 seconds
- Sustained if lasts >30 seconds

Etiology^[1]^[2]^[3]

Due to true ventricular tachycardia in 80% of cases
- For patients with underlying cardiac disease, increases to > 90%
Consider:
- Hyperkalemia
- Digoxin toxicity
- Severe metabolic acidosis

Clinical Features

Depends on etiology
Range from asymptomatic/palpitations to cardiac arrest

Differential Diagnosis

Narrow-complex tachycardia

Regular
- AV Node Independent
  - Sinus tachycardia
  - Atrial tachycardia (uni-focal or multi-focal)
  - Atrial fibrillation
  - Atrial flutter
  - Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
  - Paroxysmal supraventricular tachycardia (PSVT)
    - AV node re-entry tachycardia (AVNRT)
    - AV re-entry tachycardia (AVRT)
      - Lown-Ganong-Levine syndrome
      - Wolff–Parkinson–White syndrome
  - Junctional tachycardia
Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
  - Atrial fibrillation with RVR
- Atrial flutter with variable conduction
- Digoxin Toxicity

Wide-complex tachycardia

Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)

Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
  - PSVT with bundle branch block^
  - PSVT with accessory pathway
  - Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
  - Hyperkalemia
  - Digoxin toxicity
  - Severe metabolic acidosis
Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
  - Torsades de pointes
  - Nonsustained ventricular tachycardia

^Fixed or rate-related

Evaluation

Wide regular tachycardia consistent with ventricular tachycardia

Assume ventricular tachycardia until proven otherwise
- See rhythm diagnosis in regular wide complex tachycardia

Management

Wide Regular Tachycardia^[4]

Wide Regular Tachycardia (consistent with ventricular tachycardia).

Pulseless: see Adult pulseless arrest

Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
- Synchronized cardioversion 100-200J
Stable:
Medications
- Procainamide (first-line drug of choice)
  - 20-50 mg/min until arrhythmia suppressed (max 17mg/kg or 1 gram); then, maintenance infusion of 1-4mg/min x 6hr
    - Alternative administration: 100 mg q5min at max rate of 25-50 mg/min^[5]
  - Stop if QRS duration increases >50% or hypotension
  - Avoid if prolonged QT or CHF
  - Favored over Amiodarone in PROCAMIO trial; termination of tachycardia in 67% of procainamide group vs 38% of amiodarone group, adverse cardiac events 9% vs 41%, respectively ^[6]
- Amiodarone (agent of choice in setting of AMI or LV dysfunction)
  - 150 mg over 10min (15 mg/min), followed by 1 mg/min drip over 6hrs (360 mg total)^[7]
  - Then 0.5 mg/min drip over next 18 hrs (540 mg total)
  - Oral dosage after IV infusion is 400 -800 mg PO daily
- Consider adenosine
  - Consider for diagnosis and treatment, if rhythm is regular and monomorphic (see rhythm diagnosis in regular wide complex tachycardia)
  - 6 mg IV as a rapid IV push followed by a 20 mL saline flush; repeat if required as 12 mg IV push
- Synchronized cardioversion (100J)

Wide Irregular Tachycardia

Wide Irregular Tachycardia (consistent with Torsades De Pointes).

DO NOT use AV nodal blockers as they can precipitate V-Fib

Pulseless: see Adult pulseless arrest

Unstable: Hypotension, altered mental status, shock, ischemic chest discomfort, acute heart failure
- Unsynchronized cardioversion (defibrillation) 200J
Stable:
A fib with preexcitation
- 1st line - Electric Cardioversion
- 2nd line - Procainamide, amiodarone, or sotalol
A fib with aberrancy
Polymorphic V-Tach / Torsades De Pointes
- Give IV MgSO4
- Emergent defibrillation (NOT synchronized)
- Correct electrolyte abnormalities (esp hypoK, hypoMg)
- Stop prolonged QT meds

Recurrent

≥3 episodes within 24 hours considered electrical storm and may require alternate treatment (i.e. beta blockade, sedation, ablation)

Other considerations

True Vtach generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with WPW in which Procainamide is the treatment of choice
In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving calcium chloride to treat hyperkalemia
Consider Acidosis
Sodium channel blockade (e.g. from benadryl, TCA, or cocaine toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm
- Treat with sodium bicarbonate
- Lidocaine, Procainamide, Amiodarone all block Na channels and may result in asystole in patients with intrinsic or extrinsic Na-channel blockade

Disposition

Admit all patients (even if converted to normal sinus rhythm in ED)

External Links

References

↑ Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.
↑ Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.
↑ Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.
↑ American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org
↑ Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.
↑ Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335
↑ Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.

Authors:

[1] Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.

[2] Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.

[3] Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.

[4] American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 7: Adult Advanced Cardiovascular Life Support. ECCguidelines.heart.org

[5] Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.

[6] Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335

[7] Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.

[1]

[2]

[3]

[4]

[5]

[6]

[7]

@@ Line 1: / Line 1: @@
 ==Background==
-*Consider [[Hyperkalemia]], [[Dig Toxicity]], severe metabolic acidosis
+*3 wide complexes in a row is considered ventricular tachycardia
-*Sustained ventricular tachycardia is VT > 30 seconds
+**Non-sustained if lasts < 30 seconds
-*Less than 30 seconds, non-sustained VT
+**Sustained if lasts >30 seconds
-===Epidemiology<ref>Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.</ref><ref>Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.</ref><ref>Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.</ref>===
+===Etiology<ref>Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am. 2001;85(2):245–66– ix–x.</ref><ref>Akhtar M, Shenasa M, Jazayeri M, Caceres J, Tchou PJ. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med. 1988;109(11):905–912.</ref><ref>Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med. 1986;104(6):766–771.</ref>===
-*WCT is due to ventricular tachycardia in 80% of cases
+*Due to true ventricular tachycardia in 80% of cases
-*For patients with underlying cardiac disease, this number increases to > 90%
+**For patients with underlying cardiac disease, increases to > 90%
+*Consider:
+**[[Hyperkalemia]]
+**[[Digoxin toxicity]]
+**Severe metabolic acidosis
+==Clinical Features==
+*Depends on etiology
+*Range from asymptomatic/[[palpitations]] to [[cardiac arrest]]
 ==Differential Diagnosis==
+{{Tachycardia (narrow) DDX}}
 {{Tachycardia (wide) DDX}}
 ==Evaluation==
-[[File:Lead II rhythm ventricular tachycardia Vtach VT.jpg|thumb|Ventricular tachycardia]]
+[[File:Electrocardiogram of Ventricular Tachycardia.png|thumb|Wide ''regular'' tachycardia consistent with ventricular tachycardia]]
 *Assume ventricular tachycardia until proven otherwise
-*See [[V Tach vs. SVT]]
+**'''See [[rhythm diagnosis in regular wide complex tachycardia]]'''
 ==Management==
-''Pulseless: see [[Adult pulseless arrest]]''
+{{ACLS Wide Regular Tachycardia}}
-*Unstable:
+{{ACLS Wide Irregular Tachycardia}}
-**Regular: Synchronized cardioversion 100-200J
-**Irregular: Unsynchronized cardioversion ([[defibrillation]]) 200J
+===Recurrent===
-*Stable
+*≥3 episodes within 24 hours considered [[electrical storm]] and may require alternate treatment (i.e. beta blockade, sedation, ablation)
-**Regular (treat as presumed V-tach)
-***[[Procainamide]] 100 mg q5min at max rate of 25-50 mg/min<ref>Procainamide. GlobalRPH. http://www.globalrph.com/procainamide_dilution.htm.</ref>
+===Other considerations===
-****Until termination of arrhythmia, then start 2-6 mg/min (or 1-2 mg/min for renal/cardiac failure)
+*True [[Vtach]] generally has rate >120bpm. If rate <120bpm or refractory to other therapy, consider other causes
-****OR max 17 mg/kg total dose given (12 mg/kg if renal failure)
+*When in doubt, use cardioversion for treatment of regular WCT. In irregular WCT, consider Afib with [[WPW]] in which [[Procainamide]] is the treatment of choice
-****OR if QRS widens > 50%
+*In very wide complex (>0.2 msec) and <120 bpm in a patient with significant history, consider giving [[Calcium chloride|calcium chloride]] to treat [[Hyperkalemia|hyperkalemia]]
-***[[Amiodarone]], agent of choice in setting of AMI or LV dysfunction
+*Consider [[Acidosis]]
-****150 mg over 10min (15 mg/min), followed by 1 mg/min drip over 6hrs (360 mg total)<ref>Amiodarone. GlobalRPH. http://www.globalrph.com/amiodarone_dilution.htm.</ref>
+*Sodium channel blockade (e.g. from [[Benadryl|benadryl]], [[TCA toxicity|TCA]], or [[Cocaine toxicity|cocaine]] toxicity) may cause very wide complex (>0.2msec) tachycardia with rate <120bpm
-****Then 0.5 mg/min drip over next 18 hrs (540 mg total)
+**Treat with [[Bicarbonate|sodium bicarbonate]]
-****Oral dosage after IV infusion depends on IV infusion length:
+**[[Lidocaine]], [[Procainamide]], [[Amiodarone]] all block Na channels and may result in asystole in patients with intrinsic or extrinsic Na-channel blockade
-*****< 1 wk IV infusion: 800-1600 mg PO QD
-*****1-3 wks: 600-800 mg PO QD
-*****> 3 wks: 400 mg PO QD
-***[[Lidocaine]] 1-1.5mg/kg IV q5min, repeat prn until up to 300mg/hr
-**Irregular (treat as presumed preexcited [[A-fib]])
-***[[Procainamide]] as above
-***[[Amiodarone]] as above
-***[[Sotalol]] (100mg IV over 5 minutes)
-***[[Magnesium]] 1-2gm IV over 60-90s, then infuse 1-2gm/hr (for [[Torsades De Pointes]])
-*Refractory
-**≥3 episodes within 24 hours considered [[electrical storm]] and may require alternate treatment (i.e. beta blockade, sedation, ablation)
 ==Disposition==
-*Admit all patients (even if converted to NSR with adenosine)
+*Admit all patients (even if converted to normal sinus rhythm in ED)
 ==See Also==
 *[[ACLS: Tachycardia]]
 *[[ACLS (Main)]]
-*[[V Tach vs. SVT]]
+*[[Rhythm diagnosis in regular wide complex tachycardia]]
-*[[SVT]]
+*[[Paroxysmal supraventricular tachycardia]]
 *[[Nonsustained ventricular tachycardia]]
+*[[Polymorphic ventricular tachycardia]]
+*[[Electrical storm]]
+*[[In-Training Exam Review]]
+==External Links==
 ==References==
 <references/>
 [[Category:Cardiology]]