Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram
Open accessAbstract
Objectives The purpose of this study was to evaluate the utility of the 12-lead electrocardiogram (ECG) for differentiating paroxysmal narrow QRS complex tachycardias.Background Previous studies evaluating the utility of the 12-lead ECG for differentiating paroxysmal supraventricular tachycardia types have shown conflicting results on the usefulness of some ECG criteria, and some criteria that are considered to be useful have never been formally evaluated.Methods Two hundred forty-two ECGs demonstrating paroxysmal narrow QRS complex (< 0.11 ms) tachycardia (rate > or = 120 beats/min) were analyzed. All ECGs were analyzed by an observer who had no knowledge of the mechanism of the tachycardia.Results There were 137 atrioventricular (AV) reciprocating tachycardias, 93 AV node reentrant tachycardias and 12 atrial tachycardias. Six criteria were found to be significantly different between tachycardia types by univariate analysis. A P wave separate from the QRS complex was observed more frequently in AV reciprocating tachycardia (68%) and atrial tachycardias (75%). A pseudo r' deflection in lead V1 and a pseudo S wave in the inferior leads were more common in AV node reentrant tachycardia (58% and 14%, respectively); QRS alternans was present more often during AV reciprocating tachycardia (27%). When a P wave was present, an RP/PR interval ratio > or = 1 was more common in atrial tachycardias (89%). During sinus rhythm, manifest pre-excitation was observed more often in patients with AV reciprocating tachycardia (45%). By multivariate analysis, the presence of a P wave separate from the QRS complex, pseudo r' deflection in lead V1, QRS alternans during tachycardia and the presence of pre-excitation during sinus rhythm were independent predictors of tachycardia type. These criteria correctly identified 86% of AV node reentrant tachycardias, 81% of AV reciprocating tachycardias and incorrectly assigned the tachycardia type in 19% of cases.Conclusions Several features on the ECG are useful for differentiating supraventricular tachycardia type. However, approximately 20% of tachycardias may be incorrectly classified on the basis of analysis of the ECG; therefore, the ECG should not serve as the sole means for determining tachycardia mechanism.
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In case of relatively delayed retrograde conduction that allows identification of retrograde P waves, a pseudo-R deflection in lead V1 and a pseudo S wave in the inferior leads are more common in typical AVNRT rather than in AVRT due to an accessory pathway or atrial tachycardia.
“In case of relatively delayed retrograde conduction that allows the identification of retrograde P waves, a pseudo-R deflection in lead V1 and a pseudo S wave in the inferior leads are more common in typical AVNRT rather than in AVRT due to an accessory pathway or atrial tachycardia.22,23”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [22]
In all of these studies, cases of atrial tachycardia or atypical AVNRT were limited or entirely absent.
“However, in all of these studies, cases of atrial tachycardia or atypical AVNRT were limited or entirely absent.”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [22]
These criteria are specific (91-100%) but modestly sensitive (58-14%).
“These criteria are specific (91-100%) but modestly sensitive (58-14%).22”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [22]
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- Authors
- Kalbfleisch, S. J., El-Atassi, R., Calkins, H., Langberg, J. J., & Morady, F.
- Affiliations
- University of Michigan (US)
- Corresponding author
- Morady, Fred
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 1993-01
- Volume
- 21
- Issue
- 1
- Pages
- 85-89
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2034823756
- Cited by
- 115
- References
- 10
- Citations by year
- 2026: 2 · 2023: 5 · 2022: 3 · 2021: 4 · 2020: 6 · 2019: 2 · 2018: 4 · 2016: 3 · 2015: 8 · 2014: 2 · 2013: 4 · 2012: 5
- FWCI
- 2.53
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- supraventricular tachycardia, 12-lead ECG, atrioventricular reciprocating tachycardia, atrial tachycardia, P wave, QRS alternans, preexcitation, electrocardiographic criteria
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Analysis of Variance, Diagnosis, Differential, Electrocardiography, Humans, Middle Aged, Sensitivity and Specificity, Tachycardia, Paroxysmal, Tachycardia, Supraventricular, Observer Variation, Multivariate Analysis, Chi-Square Distribution
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