EKG of the Week

+ EKG Interpretation

VT or SVT w/ Aberrancy?

This is a really scary looking tracing. The patient is a 60 yo man with no prior cardiac hx who was acutely sob, with palpitations. He was awake, no syncope and had a decent BP.

So, this is obviously wide and fast. It is regular. So, our differential is VT vs some kind of SVT with aberrancy. Let's use Brugada criteria to help us determine:

1) Is there a monomorphic?

He does have an RS in some of V leads so not VTach based on that criteria. We have to look further.

2) If there is a QRS with an RS in a precordial lead, is the start of complex to bottom of S >100 mseconds?

No, in V3 and V4 the time between the start of the complex and bottom of the Sis very short. Again, not VT based on that criteria. We have to look further.

3) Is there AV dissociation (ie P waves that march thru unrelated to the QRS)?

No there are not.

So after "no's" to those 3 questions we have to look at the morphology criteria for VT in a patient with a tachycardia with a left bundle branch like QRS- looking at the chart he does not have those morphologic criteria for VT either.

So what do you think?

There was a LOT of discussion about this ekg. Based on above, this is a supraventricular tachycardia with a rate dependent LBBB. But it is scary looking.

Let me tell you what happened. First of all, when you see something wide and fast AND YOU CANT DECIDE what are you supposed to do? Treat it for VT, right. I think that was the plan but before any treatment, while IV being started, he spontaneously converted into AFIB, with rate not quite so fast and no left bundle branch block. Over the next few hours he converted back to sinus rhythm. His coronary arteries were clear at cath and at electrophysiology study he had an SVT and was ablated and this has not recurred.

Brugada criteria was accurate!

Further Reading:

Life in the Fast Lane: Brugada criteria, VTach

Original Brugada Article: AHA 1991

Follow up EKGs: