VT Versus SVT (With Aberrancy) : Adapted From, 2019

Adapted from Dr Ed Burns, 2019 Edited: G Euston 2019 & 2020
VT versus SVT (with aberrancy)
(SVT in the widest sense of the definition is taken to include true SVT, AF/Flutter, WPW and other re-entry syndromes.)
Unfortunately, ECG differentiation of VT from SVT with aberrancy is not always possible.
(Below is example from 2020/2 FANCA Examination – hence my 2020 revision)
Reproduced on last page of handout with the Stem question from the exam on the preceding page.
The Brugada Criteria
• The algorithm can be used to distinguish between VT and SVT with aberrancy.
• Considered an advanced criterion.
• The algorithm is followed from top to bottom — if any of the criteria are satisfied then VT
is diagnosed.
1. Absence of an RS complex in all precordial leads
This is essentially the same as having positive or negative concordance.

• All precordial leads consist of either monophasic R or S waves
o → VT is diagnosed.
• If there are any RS complexes present in V1-6
o → go to step 2.
Precordial R waves only → VT

Precordial S waves only → VT
RS complexes present → go to step 2
2. RS interval > 100ms in one precordial lead
If RS complexes are present in V1-6 then the RS interval is measured. This is the time from
the onset of the R wave to the nadir of the S wave.
• If the RS interval is > 100 ms (Brugada Sign!)
o → VT.
• If the RS interval is < 100 ms
o → go to step 3
3. AV dissociation
The ECG is scrutinised for hidden P waves; these are often superimposed on the QRS complexes
and may be difficult to see.
• P waves are present at a different rate to the QRS complexes (including fusion, capture beats)
o→ AV dissociation is present and VT is diagnosed.
• No evidence of AV dissociation can be seen
o → go to step 4
4. Morphological Criteria for VT
Leads V1-2 and V6 are assessed for characteristic features of VT. There are two sets of
morphological criteria depending on the appearance of the QRS complex in V1:
• Dominant R wave in V1
→ see criteria for RBBB-like morphology
o
• Dominant S wave in V1
o → see criteria for LBBB-like morphology
RBBB-like morphology
LBBB-like morphology
Broad complex tachycardia with RBBB morphology
Appearance in V1-2
With a positive R wave in V1/V2, three patterns are indicative of VT:
• Smooth monophasic R wave
• Notched downslope to the R wave — the taller left rabbit ear
• A qR complex (small Q wave, tall R wave) in V1
• Smooth monophasic R wave V1/V2

o → VT
• Taller left rabbit ear V1/V2

o → VT
• qR Complex V1/V2
o → VT
NOTE: RSR’ pattern is suggestive of SVT with RBBB
Appearance in V6
In V6, the following patterns are consistent with VT:
• QS complex –a completely negative complex with no R wave
• R/S ratio < 1 – small R wave, deep S wave (indicates VT only if LAD is also present).
• QS waves in V6
o → VT
• R/S ratio < 1 in V6

o → probably VT
o More likely VT if LAD
Broad complex tachycardia with LBBB morphology
Appearance in V1-2
With a dominant S wave in V1, the following three features are diagnostic of VT:
• Initial R wave > 30-40 ms duration.
• Notching or slurring of the S wave (Josephson’s sign).
• RS interval (time from R wave onset to S wave nadir) > 60-70 ms.
Image reproduced from Wellens (2001)
Dominant S Wave in V1 or V2 (LBBB Morphology)
Appearance in V6
With a LBBB-like pattern, the presence of Q waves in V6 is indicative of VT.
There are two possible patterns:
• QS waves in V6 (as with RBBB-like patterns)
o Very specific for VT
• qR pattern = small q wave; large R wave.
• QS waves in V6
o → VT
• qR complex in V6
o → VT
Note: SVT with LBBB is associated with absent Q waves in V6.

Another Advanced Tip — The Vereckei Algorithm
European Heart Journal (2007) 28, 589-600 (Hungarian – Pronounced in English: var-EhtS-keh)
There is much overlap between the Vereckei and Brugada algorithms, but one of the most useful
tips from the Vereckei algorithm is to examine the QRS complex in lead aVR.
(I know right … – Finally, a reason for aVR?)
• Dominant initial R wave in aVR
o indicative of VT.
• Dominant terminal R’ wave in aVR (ie. following a Q/S wave)
o more likely SVT with aberrancy
o pattern is most commonly seen in tricyclic poisoning.
• Dominant initial R wave in aVR

o → VT
• Dominant secondary R’ wave in aVR

o → TCA toxicity (SVT with aberrancy)
Other ECG features increasing the likelihood of VT (not mentioned in the previous criteria)
Electrocardiographic features that increase the likelihood of VT:
• Extreme axis deviation (“northwest axis”) — QRS negative in I + aVF (& positive in aVR!)
Examples of Independent Atrial Activity:
Capture beat
Fusion beats – the first of the narrower complexes is a fusion beat (the next two are capture beats)
Positive concordance in VT (Absence of RS waves)
Negative concordance in VT (Absence of RS waves)

Additional factors associated with VT or SVT
The likelihood of VT is increased with:

• Age > 35 (positive predictive value of 85%)
• Structural heart disease
• Ischaemic heart disease or Previous MI
• Congestive heart failure / Cardiomyopathy
• Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long
QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are all
associated with episodes of VT)
The likelihood of SVT with aberrancy is increased if:

• Previous ECGs show a bundle branch block pattern with identical morphology to the broad
complex tachycardia.
• Previous ECGs show evidence of WPW.
• The patient has a history of paroxysmal tachycardias that have been successfully terminated
with adenosine / vagal manoeuvres.
Conclusions
• Most of the published criteria have high specificities but very low sensitivities (e.g. 20-50%) for
diagnosing VT.
• This means that even in the absence of diagnostic features for VT, it can still be VT!
(there is no way to be 100% certain that the rhythm is SVT with aberrancy…)
• If in doubt, treat as VT! “Light ‘em up”. (but I recognise a difference of opinion – sometimes….)
The FANZCA Written Exam: 2020/2 – Q 14, (a)

Q14. ECG produced over.
This is the standard 12-lead electrocardiogram (ECG) of a 68-year-old man in the post-anaesthesia care
unit (PACU) following a revision total hip replacement. He has a history of hypertension controlled with
candesartan and hydrochlorothiazide. His preoperative ECG showed sinus rhythm with a rate of 82 per
minute.
a) Interpret this ECG and provide a differential Diagnosis
Interpretation: This is a 12 lead ECG with standard Calibration. The ventricular rate is approximately 180 bpm
showing a very regular and wide complex tachycardia; the complexes being approximately 160ms duration. The
Ventricular axis is normal. There is no positive or negative concordance of the QRS in the pre-cordial leads. In
considering Brugada Criteria - The QRS displays some RS waves in the precordial leads, and the R-S nadir appears
< 100ms (No Brugada Sign)- (against VT). There is no evidence of independent atrial activity (Against VT). The
precordial leads show a LBBB type pattern. The initial R wave in V1-2 > 30ms duration (Supports VT), but there is no
notching or slurring of the S wave (No Josephson’s sign) and the RS interval <60ms (Against VT). There are no Q
waves in V6 (Against VT). AVR shows no R wave (Vereckei Algorithm). (Against VT) (NB – No Patient Identifiers or
date of ECG are noted, No Sweep speed is presented but we are told this a standard ECG – assume 25mm/sec).
Differential Diagnosis:
1. SVT with Aberrant conduction (LBBB) – Preferred, and favoured by
• Normal Axis
• Neither positively nor negatively concorded in the precordial leads
• Absent Brugada Criteria for VT
• No R wave in AVR (Vereckei Algorithm).
2. VT – less preferred, but in favour of such is
• Wide r wave in V1 (>30ms)
While there are many and varied criteria to rule in VT in wide-complex tachycardia, there are no great/robust criteria
that would exclude the diagnosis of VT.
ECG
Q14
FANZCA
Final Exam
2020/2
From an
Exam
Candidate’s
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Adapted from Dr Ed Burns, 2019 Edited: G Euston 2019 & 2020

VT versus SVT (with aberrancy)

1. Absence of an RS complex in all precordial leads

This is essentially the same as having positive or negative concordance.

Precordial R waves only → VT

2. RS interval > 100ms in one precordial lead

4. Morphological Criteria for VT

• Smooth monophasic R wave V1/V2

• Taller left rabbit ear V1/V2

NOTE: RSR’ pattern is suggestive of SVT with RBBB

• R/S ratio < 1 in V6

Image reproduced from Wellens (2001)

Dominant S Wave in V1 or V2 (LBBB Morphology)

Note: SVT with LBBB is associated with absent Q waves in V6.

• Dominant initial R wave in aVR

• Dominant secondary R’ wave in aVR

Examples of Independent Atrial Activity:

Negative concordance in VT (Absence of RS waves)

The likelihood of VT is increased with:

The likelihood of SVT with aberrancy is increased if:

The FANZCA Written Exam: 2020/2 – Q 14, (a)

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