A new electrocardiographic algorithm using retrograde P waves for differentiating atrioventricular node reentrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway
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Objectives The purpose of this study was to use an electrocardiographic (ECG) algorithm, derived from the results of radiofrequency ablation, to discriminate atrioventricular node reentrant tachycardia (AVNRT) from atrioventricular reciprocating tachycardia (AVRT) and to localize a concealed accessory pathway, prospectively.Background Information about ECG criteria for differentiating AVNRT from AVRT is limited and has not been confirmed by surgical or catheter ablation.Methods Four hundred six ECGs (obtained from 406 different patients) that demonstrated narrow QRS complex (< 0.12 s) supraventricular tachycardia with an RP' interval less than the P'R interval or pseudo r' wave in lead V1 or pseudo S wave in inferior leads, or both, were examined, and the results were confirmed by radiofrequency catheter ablation. The initial 226 ECGs were analyzed to develop a stepwise algorithm, and the subsequent 180 ECGs were prospectively evaluated by the new algorithm.Results The presence of a pseudo r' wave in lead V1 or a pseudo S wave in leads II, III, aVF indicated anterior-type AVNRT with an accuracy of 100%. With the difference of RP' intervals in leads V1 and III > 20 ms, posterior-type AVNRT could be differentiated from AVRT utilizing a posteroseptal pathway with a sensitivity of 71% (95% confidence interval [CI] 55% to 89%), a specificity of 87% (95% CI 67% to 97%) and a positive predictive value of 75% (95% CI 56% to 91%). According to the polarity of retrograde P waves in leads V1, II, III, aVF and I during AVRT, the concealed accessory pathway could be localized to one of the nine regions on the atrioventricular annuli with an accuracy of 75% (for a right midseptal pathway) to 93.8% (for a left posterior pathway). Overall, the new algorithm had an accuracy of 97.8% in discriminating AVNRT from AVRT and 88.1% in localizing a concealed accessory pathway, prospectively. Prediction was incorrect in only 15 patients (9.1%).Conclusions The new ECG algorithm derived from the analysis of retrograde P waves during tachycardia could provide a criterion for differential diagnosis between AVNRT and AVRT and for predicting the location of concealed accessory pathways.
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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 [23]
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 [23]
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- Authors
- Tai, C.-T., Chen, S.-A., Chiang, C.-E., Lee, S.-H., Wen, Z.-C., Chiou, C.-W., Ueng, K.-C., Chen, Y.-J., Yu, W.-C., & Chang, M.-S.
- Affiliations
- National Yang Ming University (TW)
- Taipei Veterans General Hospital (TW)
- Shin Kong WHS Memorial Hospital (TW)
- Corresponding author
- Chen, Shih-Ann
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 1997-02
- Volume
- 29
- Issue
- 2
- Pages
- 394-402
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2086286754
- Cited by
- 75
- References
- 20
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 2 · 2023: 5 · 2022: 4 · 2021: 3 · 2020: 3 · 2019: 4 · 2018: 1 · 2017: 1 · 2016: 5 · 2015: 3 · 2013: 3 · 2012: 2
- FWCI
- 1.71
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Science Council
- 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
- atrioventricular reciprocating tachycardia, concealed accessory pathway, retrograde P waves, ECG algorithm, supraventricular tachycardia, radiofrequency catheter ablation, accessory pathway localization
- MeSH terms
- Adolescent, Adult, Aged, Algorithms, Child, Diagnosis, Differential, Electrocardiography, Female, Heart Conduction System, Humans, Male, Middle Aged, Prospective Studies, Sensitivity and Specificity, Tachycardia, Atrioventricular Nodal Reentry, Tachycardia, Paroxysmal
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