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Pearls and Practical Approach to Wide Complex Tachycardia

Can you distinguish SVT from VT? Here’s an approach:

  1. Assume VT until proven otherwise.
  2. Cardiovert unstable patients
  3. Key is HISTORY:
    1. Ischemic heart disease + VT until proven otherwise
    2. LV dysfunction: VT until proven otherwise.
    3. WPW/SVT/Pre-excitation: possible VT, acquire evidence.
      • i.e. PMH: WPW with irregular tachycardia
      • Atrial fib with conduction via accessory pathway?
  4. COMPARE 12 lead ECG of tachycardia to resting ECG:
    • same = SVT
    • different or not available = vtach
    • similar morphology, but “wider” supports SVT, doesn’t exclude VT
  5. Is SVT possible? No contraindication to adenosine*:
    • Adenosine 6 mg IVP. Does rhythm terminate? Record rhythm,
  6. Diagnosis uncertain?
    • Amiodarone 150 mg IV over 10 minutes
    • Procainamide: Alternative if no structural heart disease
  7. No diagnosis:
    • Consult Cardiology
    • Or Electrophysiology

**Brugada and morphology criteria are useful but cumbersome.

***Caution with use of adenosine to differentiate SVT and BVT:

Adenosine can speed up atrial flutter, and atrial fibrillation in the setting of WPW.

****Adenosine used in both VT and SVT; consult Electrophysiology Service if you plan EP study.