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A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex
Abstract
BACKGROUND: In the differential diagnosis of a tachycardia with a wide QRS complex (greater than or equal to 0.12 second) diagnostic mistakes are frequent. Therefore, we investigated the reasons for failure of presently available criteria, and we identified new, simpler criteria and incorporated them in a stepwise approach that provides better sensitivity and specificity for making a correct diagnosis. METHODS AND RESULTS: A prospective analysis revealed that current criteria had a poor specificity for the differential diagnosis. The value of four new criteria incorporated in a stepwise approach was prospectively analyzed in a total of 554 tachycardias with a widened QRS complex (384 ventricular and 170 supraventricular). The sensitivity of the four consecutive steps was 0.987, and the specificity was 0.965. CONCLUSIONS: Current criteria for the differential diagnosis between supraventricular tachycardia with aberrant conduction and ventricular tachycardia are frequently absent or suggest the wrong diagnosis. The absence of an RS complex in all precordial leads is easily recognizable and highly specific for the diagnosis of ventricular tachycardia. When an RS complex is present in one or more precordial leads, an RS interval of more than 100 msec is highly specific for ventricular tachycardia. This new stepwise approach may prevent diagnostic mistakes.
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“The morphology criteria are not fulfilled in any lead in 4% of SVTs and 6% of VTs, and in a third of cases when one lead (V 1 or V 6 ) favours one diagnosis, the other one favours the opposite diagnosis (VT in one lead and SVT the other one and vice versa).59”
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 [59]
In the citing paper
“The Brugada et al. algorithm, when all 4 steps are applied, has a sensitivity and specificity of 98.7% and 96.5%, respectively.59”
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 [59]
Citations
Cites
Wellens, H. J. J., Bär, F. W. H. M., & Lie, K. I. (1978) · The American Journal of Medicine · doi:10.1016/0002-9343(78)90176-6 · Cited by 538
Wide Complex Tachycardia: Misdiagnosis and Outcome After Emergent Therapy
Stewart, R. B., BARDY, G. H., & GREENE, H. L. (1986) · Annals of Internal Medicine · doi:10.7326/0003-4819-104-6-766 · Cited by 259
Kindwall, K. E., Brown, J., & Josephson, M. E. (1988) · The American Journal of Cardiology · doi:10.1016/0002-9149(88)91169-1 · Cited by 253
Marriott, H. J. L., & Sandler, I. A. (1966) · Progress in Cardiovascular Diseases · doi:10.1016/s0033-0620(66)80019-1 · Cited by 94
A Prevalent Misconception Regarding Wide-Complex Tachycardias
Morady, F. (1985) · JAMA · doi:10.1001/jama.1985.03360190096032 · Cited by 81
Wellens, H. J. J., Bär, F. W. H. M., Vanagt, E. J., Brugada, P., & Farré, J. (1981) · Springer eBooks · doi:10.1007/978-94-009-8239-0_11 · Cited by 75
Kistin, A. D. (1966) · Progress in Cardiovascular Diseases · doi:10.1016/s0033-0620(66)80018-x · Cited by 56
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Al‐Khatib, S. M., Stevenson, W. G., Ackerman, M. J., Bryant, W. J., Callans, D. J., Curtis, A. B., Deal, B. J., Dickfeld, T. M., Field, M. E., Fonarow, G. C., et al. (2018) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.10.054 · Cited by 1,902
Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström‐Lundqvist, C., Calkins, H. G., Corrado, D., Deftereos, S. G., Diller, G., et al. (2019) · European Heart Journal · doi:10.1093/eurheartj/ehz467 · Cited by 1,312
Al‐Khatib, S. M., Stevenson, W. G., Ackerman, M. J., Bryant, W. J., Callans, D. J., Curtis, A. B., Deal, B. J., Dickfeld, T. M., Field, M. E., Fonarow, G. C., et al. (2017) · Circulation · doi:10.1161/cir.0000000000000549 · Cited by 771
Al‐Khatib, S. M., Stevenson, W. G., Ackerman, M. J., Bryant, W. J., Callans, D. J., Curtis, A. B., Deal, B. J., Dickfeld, T. M., Field, M. E., Fonarow, G. C., et al. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.10.035 · Cited by 743
Blomström‐Lundqvist, C., Scheinman, M. M., Aliot, E., Alpert, J. S., Calkins, H. G., Camm, A. J., Campbell, W. B., Haines, D. E., Kück, K., Lerman, B. B., et al. (2003) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2003.08.013 · Cited by 684
Metadata
- Authors
- Brugada, P., Brugada, J., Mont, L., Smeets, J., & Andries, E. W.
- Affiliations
- Onze Lieve Vrouwziekenhuis Hospital (BE)
- Venue
- Circulation
- Published
- 1991-05
- Volume
- 83
- Issue
- 5
- Pages
- 1649-1659
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2026083345
- Cited by
- 738
- References
- 7
- Citations by year
- 2026: 20 · 2025: 63 · 2024: 32 · 2023: 32 · 2022: 32 · 2021: 26 · 2020: 42 · 2019: 30 · 2018: 22 · 2017: 44 · 2016: 20 · 2015: 26 · 2014: 21 · 2013: 31 · 2012: 22
- FWCI
- 6.95
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (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 › ECG Monitoring and Analysis
- Keywords
- wide QRS tachycardia, differential diagnosis, ventricular tachycardia, supraventricular tachycardia with aberrancy, precordial leads, diagnostic criteria, sensitivity and specificity
- MeSH terms
- Diagnosis, Differential, Electrocardiography, Humans, Prospective Studies, Sensitivity and Specificity, Tachycardia
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