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Groussin P, Melot A, Martins RP. PVC or Not PVC? That Is the Question. Circulation 2024; 149:1927-1930. [PMID: 38857328 DOI: 10.1161/circulationaha.124.069404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Affiliation(s)
| | - Alex Melot
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, France
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2
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William J, Kistler Mbbd PM, Kalman JM, Scheinman M, Sugumar H, Prabhu S, Ling LH, Vedantham V, Tseng Z, Moss J, Gerstenfeld EP, Voskoboinik A. Aberrancy masquerading as ventricular tachycardia: Importance of invasive electrophysiology study for diagnosis of wide complex tachycardias. J Electrocardiol 2024; 85:50-57. [PMID: 38852223 DOI: 10.1016/j.jelectrocard.2024.05.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Differentiation between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrancy based on the 12‑lead ECG alone can be imprecise. Implantable cardiac defibrillators (ICD) may be inserted for presumed VT, particularly in patients with syncopal presentation or atypical aberrancy patterns. Accurate diagnosis of these patients facilitated by an electrophysiology study (EPS) may alter diagnosis and management. METHODS We present a prospective collection of cases across 3 cardiac centers of consecutive patients with WCT presumed to be VT who were referred for consideration of an ICD, and in whom further evaluation including an EPS ultimately demonstrated SVT with aberrancy as the culprit arrhythmia. RESULTS 22 patients were identified (17 male, mean age 50±13 years. Available rhythm data at the time of referral was presumptively diagnosed as monomorphic VT in 16 patients and polymorphic VT in 6 patients. Underlying structural heart disease was present in 20 (91%). EPS resulted in a diagnosis of SVT with aberrancy in all cases: comprising AV nodal re-entry tachycardia (n=10), orthodromic reciprocating tachycardia (n=3), focal atrial tachycardia (n=3), AF/AFL (n=3) and 'double fire' tachycardia (n=2). 21 (95%) patients underwent successful ablation. All patients remained free of arrhythmia recurrence at a median of 3.4 years of follow-up. ICD insertion was obviated in 18 (82%) patients, with 1 patient proceeding to ICD extraction. CONCLUSION SVT with atypical aberrancy may mimic monomorphic or polymorphic VT. Careful examination of all available rhythm data and consideration of an EPS can confirm SVT and obviate the need for ICD therapy.
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Affiliation(s)
- Jeremy William
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Peter M Kistler Mbbd
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia
| | - Jonathan M Kalman
- The Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Melvin Scheinman
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Hariharan Sugumar
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Sandeep Prabhu
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Liang-Han Ling
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Vasath Vedantham
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Zian Tseng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Joshua Moss
- Department of Medicine, University of California, San Francisco, CA, USA
| | | | - Aleksandr Voskoboinik
- The Alfred Hospital, Melbourne, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; The Baker Heart and Diabetes Research Institute, Melbourne, Australia; The Royal Melbourne Hospital, Melbourne, Australia.
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3
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Kashou AH, LoCoco S, Gardner MR, Webb J, Jentzer JC, Noseworthy PA, DeSimone CV, Deshmukh AJ, Asirvatham SJ, May AM. Mayo Clinic VT calculator: A practical tool for accurate wide complex tachycardia differentiation. Ann Noninvasive Electrocardiol 2023; 28:e13085. [PMID: 37670480 PMCID: PMC10646384 DOI: 10.1111/anec.13085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/25/2023] [Accepted: 08/14/2023] [Indexed: 09/07/2023] Open
Abstract
The discrimination of ventricular tachycardia (VT) versus supraventricular wide complex tachycardia (SWCT) via 12-lead electrocardiogram (ECG) is crucial for achieving appropriate, high-quality, and cost-effective care in patients presenting with wide QRS complex tachycardia (WCT). Decades of rigorous research have brought forth an expanding arsenal of applicable manual algorithm methods for differentiating WCTs. However, these algorithms are limited by their heavy reliance on the ECG interpreter for their proper execution. Herein, we introduce the Mayo Clinic ventricular tachycardia calculator (MC-VTcalc) as a novel generalizable, accurate, and easy-to-use means to estimate VT probability independent of ECG interpreter competency. The MC-VTcalc, through the use of web-based and mobile device platforms, only requires the entry of computerized measurements (i.e., QRS duration, QRS axis, and T-wave axis) that are routinely displayed on standard 12-lead ECG recordings.
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Affiliation(s)
- Anthony H. Kashou
- Department of Cardiovascular MedicineMayo ClinicRochesterMinnesotaUSA
| | - Sarah LoCoco
- Department of MedicineWashington University School of MedicineSt. LouisMissouriUSA
| | | | - Jocelyn Webb
- Mayo Clinic Center for Digital HealthMayo ClinicRochesterMinnesotaUSA
| | - Jacob C. Jentzer
- Department of Cardiovascular MedicineMayo ClinicRochesterMinnesotaUSA
| | | | | | | | | | - Adam M. May
- Cardiovascular DivisionWashington University School of MedicineSt. LouisMissouriUSA
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LoCoco S, Kashou AH, Noseworthy PA, Cooper DH, Ghadban R, May AM. The emergence and destiny of automated methods to differentiate wide QRS complex tachycardias. J Electrocardiol 2023; 81:44-50. [PMID: 37517201 DOI: 10.1016/j.jelectrocard.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
Accurate differentiation of wide complex tachycardias (WCTs) into ventricular tachycardia (VT) or supraventricular wide complex tachycardia (SWCT) using non-invasive methods such as 12‑lead electrocardiogram (ECG) interpretation is crucial in clinical practice. Recent studies have demonstrated the potential for automated approaches utilizing computerized ECG interpretation software to achieve accurate WCT differentiation. In this review, we provide a comprehensive analysis of contemporary automated methods for VT and SWCT differentiation. Our objectives include: (i) presenting a general overview of the emergence of automated WCT differentiation methods, (ii) examining the role of machine learning techniques in automated WCT differentiation, (iii) reviewing the electrophysiology concepts leveraged existing automated algorithms, (iv) discussing recently developed automated WCT differentiation solutions, and (v) considering future directions that will enable the successful integration of automated methods into computerized ECG interpretation platforms.
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Affiliation(s)
- Sarah LoCoco
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, CB 8086, St. Louis, MO 63110, United States of America.
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America
| | - Daniel H Cooper
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, CB 8086, St. Louis, MO 63110, United States of America
| | - Rugheed Ghadban
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, CB 8086, St. Louis, MO 63110, United States of America
| | - Adam M May
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave, CB 8086, St. Louis, MO 63110, United States of America
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5
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Abstract
Ventricular tachycardia (VT) describes rapid heart rhythms originating from the ventricles. Accurate diagnosis of VT is important to allow prompt referral to specialist services for ongoing management. The diagnosis of VT is usually made based on electrocardiographic data, most commonly 12-lead echocardiography (ECG), as well as supportive cardiac telemetric monitoring. Distinguishing between VT and supraventricular arrhythmias on ECG can be difficult. However, the VT diagnosis frequently needs to be made rapidly in the acute setting. In this review, we discuss the definition of VT, review features of wide-complex tachycardia (WCT) on ECG that might be helpful in diagnosing VT, discuss the different substrates in which VT can occur and offer brief comments on management considerations for patients found to have VT.
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Affiliation(s)
- John Whitaker
- School of Biomedical Engineering and Imaging Sciences at King's College, London, UK and Cardiovascular Directorate Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - Matthew J Wright
- School of Biomedical Engineering and Imaging Sciences at King's College, London, UK and Cardiovascular Directorate Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - Usha Tedrow
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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6
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Kheiri B, Vedantham V, Scheinman M. A very wide complex tachycardia. Heart Rhythm 2023; 20:937-939. [PMID: 37245898 DOI: 10.1016/j.hrthm.2022.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 05/30/2023]
Affiliation(s)
- Babikir Kheiri
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Vasanth Vedantham
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California
| | - Melvin Scheinman
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, San Francisco, California.
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7
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Kashou AH, May AM, Noseworthy PA. Comparison of two artificial intelligence-augmented ECG approaches: Machine learning and deep learning. J Electrocardiol 2023; 79:75-80. [PMID: 36989954 DOI: 10.1016/j.jelectrocard.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 02/24/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Artificial intelligence-augmented ECG (AI-ECG) refers to the application of novel AI solutions for complex ECG interpretation tasks. A broad variety of AI-ECG approaches exist, each having differing advantages and limitations relating to their creation and application. PURPOSE To provide illustrative comparison of two general AI-ECG modeling approaches: machine learning (ML) and deep learning (DL). METHOD COMPARISON Two AI-ECG algorithms were developed to carry out two separate tasks using ML and DL, respectively. ML modeling techniques were used to create algorithms designed for automatic wide QRS complex tachycardia differentiation into ventricular tachycardia and supraventricular tachycardia. A DL algorithm was formulated for the task of comprehensive 12‑lead ECG interpretation. First, we describe the ML models for WCT differentiation, which rely upon expert domain knowledge to identify and formulate ECG features (e.g., percent monophasic time-voltage area [PMonoTVA]) that enable strong diagnostic performance. Second, we describe the DL method for comprehensive 12‑lead ECG interpretation, which relies upon the independent recognition and analysis of a virtually incalculable number of ECG features from a vast collection of standard 12‑lead ECGs. CONCLUSION We have showcased two different AI-ECG methods, namely ML and DL respectively. In doing so, we highlighted the strengths and weaknesses of each approach. It is essential for investigators to understand these differences when attempting to create and apply novel AI-ECG solutions.
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Affiliation(s)
- Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Adam M May
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
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8
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Kashou AH, LoCoco S, Shaikh PA, Katbamna BB, Sehrawat O, Cooper DH, Sodhi SS, Cuculich PS, Gleva MJ, Deych E, Zhou R, Liu L, Deshmukh AJ, Asirvatham SJ, Noseworthy PA, DeSimone CV, May AM. Computerized electrocardiogram data transformation enables effective algorithmic differentiation of wide QRS complex tachycardias. Ann Noninvasive Electrocardiol 2022; 28:e13018. [PMID: 36409204 PMCID: PMC9833371 DOI: 10.1111/anec.13018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/16/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Accurate automated wide QRS complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) can be accomplished using calculations derived from computerized electrocardiogram (ECG) data of paired WCT and baseline ECGs. OBJECTIVE Develop and trial novel WCT differentiation approaches for patients with and without a corresponding baseline ECG. METHODS We developed and trialed WCT differentiation models comprised of novel and previously described parameters derived from WCT and baseline ECG data. In Part 1, a derivation cohort was used to evaluate five different classification models: logistic regression (LR), artificial neural network (ANN), Random Forests [RF], support vector machine (SVM), and ensemble learning (EL). In Part 2, a separate validation cohort was used to prospectively evaluate the performance of two LR models using parameters generated from the WCT ECG alone (Solo Model) and paired WCT and baseline ECGs (Paired Model). RESULTS Of the 421 patients of the derivation cohort (Part 1), a favorable area under the receiver operating characteristic curve (AUC) by all modeling subtypes: LR (0.96), ANN (0.96), RF (0.96), SVM (0.96), and EL (0.97). Of the 235 patients of the validation cohort (Part 2), the Solo Model and Paired Model achieved a favorable AUC for 103 patients with (Solo Model 0.87; Paired Model 0.95) and 132 patients without (Solo Model 0.84; Paired Model 0.95) a corroborating electrophysiology procedure or intracardiac device recording. CONCLUSION Accurate WCT differentiation may be accomplished using computerized data of (i) the WCT ECG alone and (ii) paired WCT and baseline ECGs.
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Affiliation(s)
- Anthony H. Kashou
- Department of Cardiovascular MedicineMayo ClinicMinnesotaRochesterUSA
| | - Sarah LoCoco
- Department of MedicineWashington University School of MedicineMissouriSt. LouisUSA
| | - Preet A. Shaikh
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
| | - Bhavesh B. Katbamna
- Department of MedicineWashington University School of MedicineMissouriSt. LouisUSA
| | - Ojasav Sehrawat
- Department of Cardiovascular MedicineMayo ClinicMinnesotaRochesterUSA
| | - Daniel H. Cooper
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
| | - Sandeep S. Sodhi
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
| | - Phillip S. Cuculich
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
| | - Marye J. Gleva
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
| | - Elena Deych
- Division of BiostatisticsWashington University School of MedicineMissouriSt. LouisUSA
| | - Ruiwen Zhou
- Division of BiostatisticsWashington University School of MedicineMissouriSt. LouisUSA
| | - Lei Liu
- Division of BiostatisticsWashington University School of MedicineMissouriSt. LouisUSA
| | | | | | | | | | - Adam M. May
- Department of Medicine, Division of Cardiovascular DiseasesWashington University School of MedicineMissouriSt. LouisUSA
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9
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Lopez Perales CR, Fernandez Corredoira PM, Chabbar Boudet M. Wide Complex Tachycardia and Flecainide. JAMA Intern Med 2022; 182:988-989. [PMID: 35913719 DOI: 10.1001/jamainternmed.2022.2940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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10
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McRae A, Dunne C. Wide-complex tachycardias in the ED: how do we make good care even better? CAN J EMERG MED 2022; 24:111-112. [PMID: 35258815 DOI: 10.1007/s43678-022-00282-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/04/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Andrew McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Rm C231 Foothills Medical Centre, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada.
| | - Cody Dunne
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Rm C231 Foothills Medical Centre, 1403 29 St NW, Calgary, AB, T2N 2T9, Canada
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11
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Kashou AH, Noseworthy PA, Jentzer JC, Rafie N, Roy AR, Abraham HM, Sang PD, Kronzer EK, Inglis SS, Rezkalla JA, Julakanti RR, Saric P, Asirvatham SJ, Deshmukh AJ, DeSimone CV, May AM. Wide complex tachycardia discrimination tool improves physicians' diagnostic accuracy. J Electrocardiol 2022; 74:32-39. [PMID: 35933848 PMCID: PMC9799284 DOI: 10.1016/j.jelectrocard.2022.07.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/07/2022] [Accepted: 07/23/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Timely and accurate discrimination of wide complex tachycardias (WCTs) into ventricular tachycardia (VT) or supraventricular WCT (SWCT) is critically important. Previously we developed and validated an automated VT Prediction Model that provides a VT probability estimate using the paired WCT and baseline 12-lead ECGs. Whether this model improves physicians' diagnostic accuracy has not been evaluated. OBJECTIVE We sought to determine whether the VT Prediction Model improves physicians' WCT differentiation accuracy. METHODS Over four consecutive days, nine physicians independently interpreted fifty WCT ECGs (25 VTs and 25 SWCTs confirmed by electrophysiological study) as either VT or SWCT. Day 1 used the WCT ECG only, Day 2 used the WCT and baseline ECG, Day 3 used the WCT ECG and the VT Prediction Model's estimation of VT probability, and Day 4 used the WCT ECG, baseline ECG, and the VT Prediction Model's estimation of VT probability. RESULTS Inclusion of the VT Prediction Model data increased diagnostic accuracy versus the WCT ECG alone (Day 3: 84.2% vs. Day 1: 68.7%, p 0.009) and WCT and baseline ECGs together (Day 3: 84.2% vs. Day 2: 76.4%, p 0.003). There was no further improvement of accuracy with addition of the baseline ECG comparison to the VT Prediction Model (Day 3: 84.2% vs. Day 4: 84.0%, p 0.928). Overall sensitivity (Day 3: 78.2% vs. Day 1: 67.6%, p 0.005) and specificity (Day 3: 90.2% vs. Day 1: 69.8%, p 0.016) for VT were superior after the addition of the VT Prediction Model. CONCLUSION The VT Prediction Model improves physician ECG diagnostic accuracy for discriminating WCTs.
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Affiliation(s)
- Anthony H. Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nikita Rafie
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | - Philip D. Sang
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ellen K. Kronzer
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sara S. Inglis
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joshua A. Rezkalla
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Petar Saric
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Adam M. May
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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12
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Siroky GP, Mehta D. Diagnosing a wide complex tachycardia using basic electrophysiologic properties of the cardiac conduction system. J Arrhythm 2021; 38:115-117. [PMID: 35222757 PMCID: PMC8851580 DOI: 10.1002/joa3.12657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Gregory P. Siroky
- Department of Cardiology Division of Electrophysiology Mount Sinai MorningsideIcahn School of Medicine at Mount Sinai New York New York USA
| | - Davendra Mehta
- Department of Cardiology Division of Electrophysiology Mount Sinai MorningsideIcahn School of Medicine at Mount Sinai New York New York USA
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13
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Liu JS, Fan EH. Toxic Effects of Flecainide in a Patient With Kidney Failure and Tachyarrhythmia. JAMA Intern Med 2021; 181:1516-1518. [PMID: 34515729 DOI: 10.1001/jamainternmed.2021.5030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jerry S Liu
- Department of Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Eugene H Fan
- Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, California
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14
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Saviano M, Toriello F, Barbieri L, Carugo S. Ventricular ectopy following accessory pathway ablation in WPW syndrome. J Electrocardiol 2021; 69:119-123. [PMID: 34695778 DOI: 10.1016/j.jelectrocard.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 09/16/2021] [Accepted: 09/30/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Many Authors already described automatic activity arising from accessory pathways, but the underlying mechanism has not been clarified yet. They may be due to embryogenetic features of myocardium or may be related to specific excitability during radiofrequency ablation. CASE Our report shows that ventricular accelerated rhythm may transiently arise from the ventricular edge of a common myocardium made accessory pathway right after the ablation. No further action were required in our experience, since the phenomenon self extinguished in approximately hour. CONCLUSIONS If this manifestation represents the effect of thermal injury or if it is a real intrinsic automaticity is not fully documented and may need further reporting and investigation.
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Affiliation(s)
- Massimo Saviano
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milano, Italy.
| | - Filippo Toriello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milano, Italy
| | - Lucia Barbieri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milano, Italy
| | - Stefano Carugo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via Francesco Sforza 35, 20122 Milano, Italy
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15
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Kashou AH, LoCoco S, McGill TD, Evenson CM, Deshmukh AJ, Hodge DO, Cooper DH, Sodhi SS, Cuculich PS, Asirvatham SJ, Noseworthy PA, DeSimone CV, May AM. Automatic wide complex tachycardia differentiation using mathematically synthesized vectorcardiogram signals. Ann Noninvasive Electrocardiol 2021; 27:e12890. [PMID: 34562325 PMCID: PMC8739609 DOI: 10.1111/anec.12890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Automated wide complex tachycardia (WCT) differentiation into ventricular tachycardia (VT) and supraventricular wide complex tachycardia (SWCT) may be accomplished using novel calculations that quantify the extent of mean electrical vector changes between the WCT and baseline electrocardiogram (ECG). At present, it is unknown whether quantifying mean electrical vector changes within three orthogonal vectorcardiogram (VCG) leads (X, Y, and Z leads) can improve automated VT and SWCT classification. METHODS A derivation cohort of paired WCT and baseline ECGs was used to derive five logistic regression models: (i) one novel WCT differentiation model (i.e., VCG Model), (ii) three previously developed WCT differentiation models (i.e., WCT Formula, VT Prediction Model, and WCT Formula II), and (iii) one "all-inclusive" model (i.e., Hybrid Model). A separate validation cohort of paired WCT and baseline ECGs was used to trial and compare each model's performance. RESULTS The VCG Model, composed of WCT QRS duration, baseline QRS duration, absolute change in QRS duration, X-lead QRS amplitude change, Y-lead QRS amplitude change, and Z-lead QRS amplitude change, demonstrated effective WCT differentiation (area under the curve [AUC] 0.94) for the derivation cohort. For the validation cohort, the diagnostic performance of the VCG Model (AUC 0.94) was similar to that achieved by the WCT Formula (AUC 0.95), VT Prediction Model (AUC 0.91), WCT Formula II (AUC 0.94), and Hybrid Model (AUC 0.95). CONCLUSION Custom calculations derived from mathematically synthesized VCG signals may be used to formulate an effective means to differentiate WCTs automatically.
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Affiliation(s)
| | - Sarah LoCoco
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Trevon D McGill
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher M Evenson
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Abhishek J Deshmukh
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel H Cooper
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Sandeep S Sodhi
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Phillip S Cuculich
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Adam M May
- Division of Cardiovascular Diseases, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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16
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Affiliation(s)
- Maxime Cerantola
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeffrey Arkles
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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17
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Lee S, Siroky GP, Suri R. Home Diagnosis of Wide Complex Tachycardia-The Value for Remote Monitoring. JAMA Intern Med 2021; 181:1234-1236. [PMID: 34309631 DOI: 10.1001/jamainternmed.2021.3194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shawn Lee
- Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory P Siroky
- Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ranjit Suri
- Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York
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18
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Ching CK, Leong BSH, Nair P, Chan KC, Seow E, Lee F, Heng K, Sewa DW, Lim TW, Chong DTT, Yeo KK, Fong WK, Anantharaman V, Lim SH. Singapore Advanced Cardiac Life Support Guidelines 2021. Singapore Med J 2021; 62:390-403. [PMID: 35001112 PMCID: PMC8804484 DOI: 10.11622/smedj.2021109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.
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Affiliation(s)
- Chi Keong Ching
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Praseetha Nair
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Kim Chai Chan
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Francis Lee
- Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore
| | - Kenneth Heng
- Emergency Medicine Department, Tan Tock Seng Hospital, Singapore
| | - Duu Wen Sewa
- Department of Respiratory Medicine, Singapore General Hospital, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Hospital, Singapore
| | | | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Wee Kim Fong
- Department of Anaesthesia, Tan Tock Seng Hospital, Singapore
| | | | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
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19
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Integrating Electrocardiography and Vectorcardiography in the Differential Diagnosis of Wide Complex Tachycardia in a Patient with Left Ventricular Noncompaction: A Case Report and Brief Literature Review. Diagnostics (Basel) 2021; 11:diagnostics11071152. [PMID: 34202450 PMCID: PMC8307937 DOI: 10.3390/diagnostics11071152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/14/2021] [Accepted: 06/22/2021] [Indexed: 11/17/2022] Open
Abstract
A 69-year-old woman with a history of hypertension and obesity, hospitalized with atypical chest pain, was diagnosed with left ventricular noncompaction. In-hospital monitoring of the cardiac rhythm revealed multiple episodes of atrial tachycardia and one episode of wide complex tachycardia (WCT) with left bundle branch block-like morphology and a right superior QRS axis. The electrocardiographic criteria were suggestive of a supraventricular origin of the WCT. Given the importance of reaching the correct diagnosis when dealing with a WCT, we tried to further define the pattern of ventricular activation using vectorcardiography (VCG). We analyzed the QRS loops during WCT in comparison to a sinus beat, a narrow complex tachycardia beat, and a premature ventricular contraction. The fast initial activation seen in the efferent limb of the QRS loop during the WCT was thought to be reflective of the fast initial activation via the conduction system seen in SVT with aberrancy, which was our final diagnosis for the WCT episode. This case illustrates a novel use of vectorcardiography as an additional diagnostic tool in the differential diagnosis of WCT.
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20
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Ding WY, Mahida S. Wide complex tachycardia: differentiating ventricular tachycardia from supraventricular tachycardia. Heart 2021; 107:1995-2003. [PMID: 34035115 DOI: 10.1136/heartjnl-2020-316874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Saagar Mahida
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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21
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Abualsuod AM, Miller JM. Removing the complexity from wide complex tachycardia. Trends Cardiovasc Med 2021; 32:221-225. [PMID: 33838244 DOI: 10.1016/j.tcm.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/03/2021] [Accepted: 04/04/2021] [Indexed: 12/13/2022]
Abstract
Correctly diagnosing the cause of wide QRS tachycardias remain an area of difficulty for many clinicians. The authors provide a concise update to the different ECG algorithms that have been developed as well as caveats in their application.
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Affiliation(s)
- Amjad M Abualsuod
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, E-488 1800 N. Capitol Ave., Indianapolis, IN 46202, United States
| | - John M Miller
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, E-488 1800 N. Capitol Ave., Indianapolis, IN 46202, United States.
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22
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Evenson CM, Kashou AH, LoCoco S, DeSimone CV, Deshmukh AJ, Cuculich PS, Noseworthy PA, May AM. Conceptual and literature basis for wide complex tachycardia and baseline ECG comparison. J Electrocardiol 2021; 65:50-54. [PMID: 33503517 DOI: 10.1016/j.jelectrocard.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Christopher M Evenson
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, USA
| | | | - Sarah LoCoco
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, USA
| | | | | | - Phillip S Cuculich
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, USA
| | | | - Adam M May
- Department of Medicine, Division of Cardiovascular Diseases, Washington University School of Medicine in St. Louis, USA.
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23
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Yang XY, Song XT, Zhang Y. Wide QRS Complex Tachycardia With a Dominant R-Wave in Lead aVR-Is It Ventricular Tachycardia? JAMA Intern Med 2020; 180:1682-1684. [PMID: 32955548 DOI: 10.1001/jamainternmed.2020.4759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Xiao-Yan Yang
- The first affiliated hospital of Hunan normal university, Hunan Provincial People's Hospital, Changsha City, Hunan Province, Changsha, China
| | - Xin-Tian Song
- People's hospital of LaoLing, Dezhou City, Shandong Province, Dezhou, China
| | - Yi Zhang
- The first affiliated hospital of Hunan normal university, Hunan Provincial People's Hospital, Changsha City, Hunan Province, Changsha, China
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24
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Subramany S, Kattoor AJ, Kovelamudi S, Devabhaktuni S, Mehta JL, Vallurupalli S, Paydak H, Pothineni NVK. Utility of Inferior Lead Q-waveforms in diagnosing Ventricular Tachycardia. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820953416. [PMID: 32943967 PMCID: PMC7466884 DOI: 10.1177/1179546820953416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/31/2020] [Indexed: 11/16/2022]
Abstract
Background Electrocardiogram (ECG) differentiation of wide complex tachycardia (WCT) into ventricular tachycardia (VT) and supraventricular tachycardia with aberration (SVT-A) is often challenging. Objective To determine if the presence of Q-waveforms (QS, Qr, QRs) in the inferior leads (II, III, aVF) can differentiate VT from SVT-A in a WCT compared to Brugada algorithm. We studied 2 inferior lead criteria namely QWC-A where all the inferior leads had a similar Q wave pattern and QWC-B where only lead aVF had a Q-waveform. Methods A total of 181 consecutive cases of WCT were identified, digitally separated into precordial leads and inferior leads and independently reviewed by 2 electrophysiologists. An electrocardiographic diagnosis of VT or SVT-A was assigned based on Brugada and inferior lead algorithms. Results were compared to the final clinical diagnosis. Results VT was the final clinical diagnosis in 24.9% of ECG cohort (45/181); 75.1% (136/181) were SVT-A. QWC-A and QWC-B had a high specificity (93.3% and 82.8%) and accuracy (78.2% and 71.0%), but low sensitivity (33.3% and 35.6%) in differentiating VT from SVT-A. The Brugada algorithm yielded a sensitivity of 82.2% and specificity of 68.4%. Area under the curve in ROC analysis was highest with Brugada algorithm (0.75, 95% CI 0.69-0.81) followed by QWC-A (0.63, 95% CI 0.56-0.70) and QWC-B (0.59, 95% CI 0.52-0.67). Conclusion QWC-A and QWC-B criteria had poor sensitivity but high specificity in diagnosing VT in patients presenting with WCT. Further research combining this simple criterion with other newer diagnostic algorithms can potentially improve the accuracy of the overall diagnostic algorithm.
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Affiliation(s)
- Swathi Subramany
- Division of Internal medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Swathi Kovelamudi
- Division of Cardiovascular medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Subodh Devabhaktuni
- Division of Cardiovascular medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jawahar L Mehta
- Division of Cardiovascular medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Division of Cardiovascular medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hakan Paydak
- Division of Cardiovascular medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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25
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Kashou AH, Noseworthy PA, DeSimone CV, Deshmukh AJ, Asirvatham SJ, May AM. Wide Complex Tachycardia Differentiation: A Reappraisal of the State-of-the-Art. J Am Heart Assoc 2020; 9:e016598. [PMID: 32427020 PMCID: PMC7428989 DOI: 10.1161/jaha.120.016598] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The primary goal of the initial ECG evaluation of every wide complex tachycardia is to determine whether the tachyarrhythmia has a ventricular or supraventricular origin. The answer to this question drives immediate patient care decisions, ensuing clinical workup, and long‐term management strategies. Thus, the importance of arriving at the correct diagnosis cannot be understated and has naturally spurred rigorous research, which has brought forth an ever‐expanding abundance of manually applied and automated methods to differentiate wide complex tachycardias. In this review, we provide an in‐depth analysis of traditional and more contemporary methods to differentiate ventricular tachycardia and supraventricular wide complex tachycardia. In doing so, we: (1) review hallmark wide complex tachycardia differentiation criteria, (2) examine the conceptual and structural design of standard wide complex tachycardia differentiation methods, (3) discuss practical limitations of manually applied ECG interpretation approaches, and (4) highlight recently formulated methods designed to differentiate ventricular tachycardia and supraventricular wide complex tachycardia automatically.
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Affiliation(s)
| | | | | | | | | | - Adam M May
- Cardiovascular Division Washington University School of Medicine St. Louis MO
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