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18/09/2015
Vereckeicriteriaasadiagnostictoolamongstemergencymedicineresidentstodistinguishbetweenventriculartachycardiaandsupraventriculartachycardiawithaberrancy
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JournalofCardiology
Summary
Keywords
Introduction
Methods
Results
Limitations
Conclusion
Acknowledgments
References
Cover
image
Volume59,Issue3,May2012,Pages307312
Originalarticle
Vereckeicriteriaasadiagnostictoolamongstemergency
medicineresidentstodistinguishbetweenventricular
tachycardiaandsupraventriculartachycardiawithaberrancy
Figures and tables
RupenP.Baxi,MDa,KimberlyW.Hart,MAa,AndrsVereckei,MDb,JohnMiller,MDc,
SoraChung,MDa,WendyChang,MDa,BrentGottesman,MDd,MeaganHunt,MDa,
GingerCulyer,MDa,ThomasTrimarco,MDa,ChristopherWilloughby,MDe,Guillermo
Suarez,MDa,ChristopherJ.Lindsell,PhDa,SeanP.Collins,MD,MScf, ,
Table 1
UnderanElsevieruserlicense
Showmore
doi:10.1016/j.jjcc.2011.11.007
Table 2
Getrightsandcontent
Table 3
OpenArchive
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Summary
Background
http://www.sciencedirect.com/science/article/pii/S0914508711002279
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Accurateelectrocardiographic(ECG)differentiationofventriculartachycardia(VT)from
supraventriculartachycardiawithaberrancy(SVTA)onECGiskeytotherapeutic
decisionmakingintheemergencydepartment(ED)setting.
Objective
Thegoalofthisstudywastotesttheaccuracyandagreementofemergencymedicine
residentstodifferentiateVTfromSVTAusingtheVereckeicriteria.
Methods
Sixemergencymedicineresidentsvolunteeredtoparticipateinthereviewof114ECGs
from86patientswithadiagnosisofeitherVTorSVTAbasedonanelectrophysiology
study.Theresidentreviewersinitiallyread12leadECGsblindedtoclinicalinformation,
andthenoneweeklaterreviewedasubsetofthesame12leadECGsunblindedto
clinicalinformation.
Results
Onereviewerwasexcludedforfailingtofollowstudyprotocolandonereviewerwas
excludedforreviewinglessthan50blindedECGs.Theremainingfourreviewerseach
read114commonECGsblindedtoclinicaldataandtheirdiagnosticaccuracyforVTwas
74%(sensitivity70%,specificity80%),75%(sensitivity76%,specificity73%),61%
(sensitivity81%,specificity25%),and68%(sensitivity84%,specificity40%).The
intraclasscorrelationcoefficient(ICC)was0.31(95%CI0.220.42).Eliminatingtwoof
thefourreviewerswholeftadisproportionatelyhighnumberofECGsunclassified
resultedinanincreaseinoverallmeandiagnosticaccuracy(7074%)andagreement
(0.310.50)inthetworemainingreviewers.Threereviewersread45commonECGs
unblindedtoclinicalinformationandhadaccuraciesforVT93%,93%and78%.
Conclusion
ThenewsingleleadVereckeicriteria,whenappliedbyemergencymedicineresidents
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achievedonlyfairtogoodindividualaccuracyandmoderateagreement.Theadditionof
clinicalinformationresultedinsubstantialimprovementintestcharacteristics.Further
improvements(accuracyandsimplification)ofalgorithmsfordifferentiatingVTfrom
SVTAwouldbehelpfulpriortoclinicalimplementation.
Keywords
VereckeiVentriculartachycardiaWidecomplextachycardia
Introduction
Background
Thetreatmentofsupraventriculartachycardiawithaberrancy(SVTA)differsfrom
ventriculartachycardia(VT)inhemodynamicallystablepatients.Atrioventricular(AV)
nodalblockingagentsareoftenthepreferredmethodofchoiceinSVTA,butcanresult
inadverseclinicalconsequencesinVT[1]and[2].Differentiatingbetweenthesetwo
widecomplextachycardiasiskeytotherapeuticdecisionmaking,butcanbe
challenging.Intheemergencydepartment(ED)setting,thedifferentialdiagnosisismost
oftenbasedonhistory,physicalexamination,andelectrocardiographic(ECG)
interpretation.AccurateECGinterpretationwithrecognitionofthedifferentrhythms
contributestoappropriatemanagementofthesepatients.
InanefforttohelpdistinguishbetweenVTandSVTA,Brugadaproposedasetof
sequentialcriteriaagainstwhichtocompareanECG[3].However,emergency
physiciansfrequentlydisagreedwitheachotherandwithcardiologistsintheir
interpretationoftheECGusingthesecriteriastudiessuggestmoderateagreementat
bestwithreportedkappastatisticsrangingfrom0.42to0.58[4]and[5].Vereckei
proposedanewsetofcriteriathataimedtosimplifytheBrugadaalgorithmbyeliminating
theneedforinterpretingcomplexmorphologicalcriteria.Instead,Vereckei'sapproachin
Step4usesanestimationofinitial(vi)andterminal(vt)ventricularactivationvelocityratio
(vi/vt).Thisresultsinthealgorithmhavingoverallgreaterdiagnosticaccuracythanthe
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Brugadacriteria(90.7%vs85.5%)[1].Withafurthermodificationthatrestrictsthe
analysistoonlytheaVRlead,thealgorithmwasshowntodistinguishbetweendifferent
rhythmsonwideQRScomplextachycardiawithanoveralltestaccuracyof91.5%[6](
Fig.1).Whetheremergencyphysicianscanaccuratelyapplythesecriteriahasnotyet
beendetermined.Further,howconsistenttheyareintheiraccuracyfromoneECGtothe
nextisimportant.Ifaccuraciesaresimilar,butagreementisdisparate,itsuggeststhe
reproducibilityofthecriteriamaybelow.
Figure1.
TheVereckeiandBrugadaalgorithms.SVT,supraventriculartachycardiawithaberrancyVT,ventricular
tachycardiav i/v t,initial(v i)andterminal(v t)ventricularactivationvelocityratioSN=sensitivity
SP=specificity.
Figureoptions
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Goalsofthisinvestigation
Thisstudywasdesignedtotesttheaccuracyofemergencymedicineresidents
determinationofthecauseofwideQRScomplextachycardiausingVereckei'sproposed
criteria.Inaddition,weexploredagreementbetweenphysicians,andwhetherthe
additionofclinicalinformationaboutthepatienthadanimpactonthediagnostic
accuracy.
Methods
Studydesign
Thiswasanobservationaldiagnosticstudy,whichwasapprovedbythelocalInstitutional
ReviewBoard.
Subjectsandsetting
PatientdataandECGswereprovidedwithoutidentifiersbyoneoftheauthors(AV).
TheseECGswerethoseusedforearlierevaluationsofthediagnosticaccuracyofthe
Vereckeicriteria[3],andincludedECGsfrom86uniquepatientswithadiagnosisof
eitherVTorSVTAbasedonanelectrophysiologystudy.TheECGswereobtainednear
thetimeoftheelectrophysiologystudy.Sixemergencymedicineresidentsparticipatedin
theECGreview.Theresidentswerefromanacademiccenterwithanemergency
medicineresidencythatisa4yearprogramwith48totalresidents.
Selectionofparticipants
Alloftheresidentsintheresidencyprogramwereofferedtheopportunitytoparticipatein
thestudy.Timecommitmentwasoutlinedsoresidentsknewwhethertheywouldbeable
tovolunteer.ThesixresidentsreceivedanoverviewoftheVereckeicriteriaandhowthey
wereappliedduringaformallecture,aswellasreceivingcopiesofbothVereckeiarticles
whichtheycouldrefertowhentheywerereviewingthe12leadECGs.
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Studydesign
Theresidentreviewersweregivencopiesofthemanuscriptsdescribingtheoriginaland
thesimplifiedVereckeicriteria[1]and[6]andafigureofthecriteriaforreferenceduring
12leadECGreview(Fig.1).Theyweretheninstructedtoindependentlyreviewthe119
ECGsblindedtoclinicalinformation.Atleastoneweekaftercompletionoftheblinded
review,thereviewerswereaskedtoreview50ofthesameECGsincombinationwith
clinicalinformationwhichincludedage,sex,pastmedicalhistory,andoutpatient
medications.Allreviewerswereblindedtothecriterionstandarddiagnosisregardlessof
whetherclinicalinformationwasavailable.Reviewerscompletedastandardizeddata
collectionformforeachECGreadingthatincludeddiagnosis(SVTA,VT,or
indeterminate)aswellaswhichstepofthealgorithmdeterminedthediagnosis.
Indextestandcriterionstandard
TheindextestwastheinterpretationoftheECGusingthesequentialVereckeicriteria
showninFig.1.Forthisstudy,thecriterionstandarddiagnosiswastheresultofan
electrophysiologystudyconductedatthetimeofthepatient'shospitalization.
Dataanalysis
Dataaresummarizedusingmediansandrangesandcountsandpercentagesunless
otherwiseindicated.AccuracyofECGinterpretationwascalculatedastheproportionof
correctlyidentifiedarrhythmias(VTvsSVTA).Testcharacteristicscalculatedforeach
residentincludedsensitivity,specificity,andlikelihoodratios(LR).Theintraclass
correlationcoefficient(ICC)wasusedasasummarymeasureofagreement,and
diagnosticteststatisticswerealsocomputed.Caseswhichwereunclassifiedbythe
residentsweretreatedasincorrectanswers.AllanalyseswereconductedusingSPSS
18.0forWindows(SPSSInc.,Chicago,IL,USA).
Results
TheECGreadingsprovidedbyonereviewerwereexcludedforfailuretofollowstudy
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protocol.Thisreviewerhadnotcompletedthecasereportformcorrectly.Onereviewer
reviewedlessthan50blindedECGsandwasexcludedfromtheblindedanalysis.
Blindedanalysiswascompletedusing114commonECGsfrom86patients,readbyfour
reviewers.Ofthese,74/114(65%)hadVTdiagnosedbythecriterionstandard.Threeof
thefiveremainingreviewersread45commonECGsunblindedtoclinicaldata.Those
ECGswithacriterionstandardofVTweremorelikelythanthosewithoutacriterion
standardofVTtohaveahistoryofmyocardialinfarction[40/79(51%)vs1/40(3%)],
previousventriculararrhythmias[19/79(24%)vs0/40(0%)],ahistoryofcardiomyopathy
[11/79(14%)vs1/40(3%)],anduseofantiarrhythmicmedications[37/79(47%)vs2/40
(5%)].
Blindedtoclinicaldata,thediagnosticaccuracyofthefourreviewersforVTwas74%
(95%CI6581%),75%(95%CI6582%),61%(95%CI5270%),and68%(95%CI
5977%)(Table1).Theoverallmeanaccuracyamongstthefourreviewerswas70%.
TheICCwas0.31(95%CI0.220.42p<0.001).Completeagreementamongstthefour
reviewersonthecorrectdiagnosisoccurredon38/114(33%)oftheECGs,andin11/114
cases(10%)thefourreviewersagreedcompletelyonanincorrectdiagnosis.Complete
agreementbyallreviewersonthecorrectdiagnosisateachindividualstepshowsthis
occurred:atStep15/114(4%)ofthetime,atStep20/114(0%),Step30/114(0%),and
Step42/114(2%).
Table1.
Testcharacteristicsforventriculartachycardiafor114electrocardiogramsreadby4residentreviewers
blindedtoclinicaldata.
Accuracy
Sensitivity
Specificity
Likelihoodratio+
Likelihoodratio
#
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
73.7
64.5
81.3
70.3
58.4
80.1
80.0
63.9
90.4
3.51
2.49
4.95
0.37
0.25
0.52
74.6
65.4
82.0
75.7
64.1
84.6
72.5
55.9
84.9
2.75
1.97
3.85
0.34
0.22
0.49
61.4
51.8
70.2
81.1
70.0
88.9
25.0
13.2
41.5
1.08
0.78
1.50
0.76
0.37
1.64
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68.4
59.0
76.6
83.8
73.0
91.0
40.0
25.3
56.6
1.40
1.01
1.93
0.41
0.21
0.73
#,reviewernumber.
Tableoptions
Twoofthefourreviewersleftadisproportionatelyhighnumber[41(36%)and23(20%)]
ofECG'sunclassifiedwhentheyarrivedatthefinalalgorithmstep.Eliminatingthesetwo
reviewersfromtheanalysisresultedinanincreaseinoverallmeanaccuracyforVTinthe
tworemainingreviewersfrom70%to74%.Further,agreementalsoimprovedfroman
ICCof0.31(95%CI0.220.42)to0.50(95%CI0.350.63,p<0.001).
Individualrevieweraccuracyacrossalgorithmstepswasvaried.Whenoverallaccuracy
wasconsidered,Step1was73%,Step2was86%,Step3was89%,andStep4was
67%.Threeofthefourreviewersachievedahighernumberofcorrectindividual
diagnosesofVTatStep1thananyotherstep(Fig.2).Thereviewersmadefewer
decisionsatSteps2and3,untilStep4whereagreaterproportionofincorrectand
indeterminatedecisionswereselected.
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Figure2.
CorrectdiagnosisbyStepperreviewer.ECG,electrocardiogramVT,ventriculartachycardia.
Figureoptions
Therewere45ECGsthatwerereviewedunblindedtoclinicalinformation.Medical
comorbiditieswerecommon,includingahistoryofmyocardialinfarctionin41(34.5%),
previousventriculararrhythmiasin19(16.0%),ahistoryofcardiomyopathyin312
(10.0%),anduseofantiarrhythmicmedicationsin39(32.8%).Forthe45ECGsthat
werereviewedbothblindedandunblindedtoclinicaldata,thethreereviewers
accuraciesforVTwere84%(95%CI7093%),78%(95%CI6388%),and84%(95%
CI7092%)whenblinded,and93%(95%CI8198%),93%(95%CI8198%),and78%
(95%CI6388%),whenunblinded,respectively(Table2andTable3,respectively).The
ICCinthissubsetofECGswas0.39(95%CI0.210.57p<0.001)whenblindedto
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clinicaldata,and0.38(95%CI0.200.57p<0.001)whenunblinded.Complete
agreementoncorrectdiagnosisbyallreviewersoccurredin27/45(60%)caseswhen
blinded,and32/45(71%)caseswhenunblinded.
Table2.
blindedtoclinicaldata.
Accuracy
Sensitivity
Specificity
Likelihoodratio+
Likelihoodratio
#
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
84.4
69.9
93.0
82.9
67.4
92.3
100
39.6
97.6
77.8
62.5
88.3
80.5
64.6
90.6
50.0
9.2
90.8
1.61
0.60
4.34
0.39
0.12
1.90
84.0
70.3
92.4
87.0
73.0
94.6
50.0
9.2
90.8
1.74
0.65
4.66
0.26
0.08
1.32
#,reviewernumber.
Tableoptions
Table3.
unblindedtoclinicaldata.
Accuracy
Sensitivity
Specificity
Likelihoodratio+
Likelihoodratio
#
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
(95%CI)
%
93.3
80.7
98.3
92.7
79.0
98.1
100
39.6
97.6
0.07
0.02
0.19
93.3
80.7
98.3
97.6
85.6
99.9
50.0
9.2
90.8
1.95
0.73
5.21
0.05
0.01
0.26
77.8
62.5
88.3
80.5
64.6
90.6
50.0
9.2
90.8
1.61
0.60
4.34
0.39
0.12
1.90
#,reviewernumber.
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Tableoptions
Discussion
OurresultssuggestthatwhenusingVereckei'sproposedsingleleadcriteriafor
differentiatingSVTAfromVT,themeandiagnosticaccuracyofemergencymedicine
residentsforVTdiagnosiswasonlyfairtogood(6175%)whenblindedtoclinicaldata.
AlargenumberofECGswereleftasindeterminatebythereviewerssuggestingthey
haddifficultyconsistentlyapplyingthecriteria.However,inthesubsetofECGsforwhich
reviewswererepeatedunblindedtoclinicaldatatheiraccuracywasgoodtoexcellent
(7893%).ThetestcharacteristicssuggestLRsthatwerenotclinicallymeaningful
(greaterthan0.1andlessthan10)whenthealgorithmwasusedinisolation,without
clinicalinformation.However,whenreviewerswereunblindedtoclinicalinformation,
diagnosticaccuracyimprovedandtheLRsuggeststhatansweringnotoall4stepsof
theVereckeicriteria(Table3)couldconfidentlyidentifyapatientwithSVTA.Further,
residentcomfortlevelwithalgorithminterpretationappearedtohaveanimpactonthe
accuracyoftheresident'sutilizationofthealgorithm.Thetworesidentswholeftveryfew
ECGsintheunclassifiedcategoryhadincreaseddiagnosticaccuracy(74%vs70%)
whencomparedtothosewholeftalargeproportionofECGsunclassified.
Agreementwaslowtomoderate(0.310.60)amongsttheresidents.Indeed,allfour
reviewersagreedonthecorrectdiagnosisinonlyonethirdoftheECGsreviewedblinded
toclinicaldata.AgreementalsovariedwitheachStepinthealgorithm.Similartoits
impactondiagnosticaccuracy,residentcomfortlevelwithalgorithminterpretationalso
appearedtohaveanimpactonagreement,asthereviewerswholeftfewECGsas
unclassifiedhadhigherlevelsofagreementwitheachother.Theadditionofclinical
informationwashelpfulinimprovingdiagnosticaccuracyandagreementamongstthe
residentreviewers.
Interestingly,thereviewersappearedtouseStep1tocorrectlycategorizealarge
proportionofpatientswithVT.Steps2and3wereusedlessfrequently,andStep4
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resultedinalargeproportionofpatientswitheitherincorrectorindeterminateECGs.This
waslikelyareflectionofECGsthatweredifficulttointerpretthroughallfoursteps,orthe
comfortleveloftheresidentsapplyingSteps2and3ofthealgorithm.Further,the
utilizationofStep4byskilledcardiologistsmayhavebeenhelpfulinpriorstudies,butthis
stepwasparticularlyproblematicinourstudyofresidents.Determiningthemagnitudeof
theinitial(vi)andterminal(vt)40msoftheQRScomplexontheECGcanbedifficultinan
ECGwheretheQRSvoltageisloworthereisafastventricularrate.Whileevaluationof
theactivationvelocityratioappearstoaccuratelydifferentiateVTfromSVT,its
interpretationmayneedtobesimplifiedfurthertoimproveitsgeneralizabilityforED
residents.Unblindingofclinicalinformationappearedtoimprovetheproportionof
patientswiththecorrectdiagnosesfortwoofthethreereviewers,from84%to93%,and
78%to93%.ManyofthesubjectswhoseECGswerereviewedunblindedtoclinical
informationhadcardiovascularcomorbidities,likelyinfluencingthereviewersdecision
makingprocess.Previousstudiessuggestcoronaryarterydisease,structuralheart
disease,historyofmyocardialinfarctionorcongestiveheartfailure,age>35years,and
malesexhavebeenassociatedwithincreasedlikelihoodofVT[2].
Limitations
Ourdatasuggest,despitefairtogoodaccuracy,agreementbetweenemergency
medicineresidentsECGinterpretationfordistinguishingbetweenVTandSVTAisonly
moderate.Theseresultsshouldbetemperedbyseverallimitations.Thenumberof
ECGswithanindependentcriterionstandardavailablewaslimited,notallresidents
reviewedallECGsasplanned,andthenumberofresidentswassmall.TheECGsthat
werenotreadmayhavebeenthosemostdifficulttointerpret,soexcludingtheseECGs
orreviewerscouldfalselyincreasethediagnosticaccuracy.Also,theblindedand
unblindedsetswerederivedfromthesamepoolofECGs,allowingforthepossibilityof
recallbias.Tominimizethispossibility,theresidentsreviewedtheblindedandunblinded
setsatleastoneweekapartandwerenotawareofthecorrectdiagnosisuntilafter
completionofthestudy.However,itispossiblethatwithonlyoneweekinbetweenthe
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tworeviewsandthesmallernumberofECGstherewasrecallbias.Further,theresidents
reviewedECGsknowingtheywereeitherSVTAorVT,whichisnottypicalofpractice,
andmayhavehadanimpactontheirperformance.Finally,inpractice,treatment
decisionsalsodependonpatientstability,thuspossiblyhavinganimpactonhow
residentsmayclassifytheECGs.
TheECGsusedforthisstudywereobtainedinpatientsreferredforelectrophysiology
testingtodeterminetheirunderlyingarrhythmiadiagnosis.Thiscouldintroducereferral
biasintoourstudy,leadingtoahigherprevalenceofVTinourcohortcomparedtoan
unselectedcohortofEDpatientswithwidecomplextachycardia.Further,togeneralize
fromourresultsrequirestheassumptionthattheECGobtainedatthetimeofthe
electrophysiologyworkupwouldbeequivalentwithanECGperformedintheED.
However,ourapproachensuredanindependentcriterionstandardobtainedatthesame
timeastheECG.
Sincetherecruitedresidentswerefromthefirstthroughfourthyearoftraining,we
suspectedtheexperienceleveloftheresidentcouldimpactaccuracy.However,wewere
onlyabletodirectlycomparetworesidentsfromdifferentlevelsoftraining.Whilea
secondyearresidentperformedbetterthanafourthyearresidentreviewing114ECGs
blindedtoclinicalinformation,weareunabletomakeanysignificantconclusions.Future
researchshouldconsiderhowtraining,bothingeneralandspecifictoapplicationof
criteriasuchasthoseproposedbyVereckei,aswellasthetimetheresidentspent
familiarizingthemselveswiththearticlesandreviewingtheECGs,mighthaveanimpact
onaccuracyofdifferentiatingthecausesofwideQRScomplextachycardia.
Wechosetohavethecriterionstandardbetheresultsoftheelectrophysiologystudy.We
couldhavechosentouseacardiologist'sinterpretationoftheVereckeicriteriaasthe
criterionstandard.However,choosingacardiologyoverreadwouldonlyletusknowhow
aresidentagreedwithacardiologistandnotwhetherthecriteriacouldbeusedtomakea
diagnosisanddirectaclinicalaction.
Conclusion
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ThenewsingleleadVereckeicriteria,whenappliedbyemergencymedicineresidents
achievedonlyfairtogoodindividualaccuracyandmoderateagreement.Theadditionof
clinicalinformationresultedinsubstantialimprovementintestcharacteristics.Test
characteristicssuggestedveryfewfalsenegatives,suchthatansweringnotoall4
stepsoftheVereckeicriteriacouldidentifyapatientwithSVTA.Residentswhowere
abletoapplythealgorithminthemajorityoftheECGshadbetteraccuracyand
agreementwhencomparedtoagroupofresidentswholeftalargeproportionofECGsas
uninterpretable.Furtherimprovements(accuracyandsimplification)ofalgorithmsfor
differentiatingVTfromSVTAwouldbehelpfulpriortoclinicalimplementation.
Acknowledgments
SPCconceivedthestudy,whichwasdesignedwithinputfromCJL.SC,WC,BG,MH,
GC,TT,CW,GSparticipatedincollectionandinterpretationofthedata.RPBwas
responsiblefordatamanagement.KWHandCJLwereresponsibleforstatistical
analysis.RPBdraftedthemanuscriptandallauthorscontributedsignificantlytoits
revisionandapprovedthefinalversion.SPCtakesresponsibilityforthemanuscriptasa
whole.
ThisworkwassupportedinpartbyNationalHeart,LungandBloodInstitutegrant
K23HL085387andanInstitutionalClinicalandTranslationalScienceAwardNIH/NCRR
GrantNumber5UL1RR02631403.
References
[1]
A.Vereckei,G.Duray,G.Szenasi,G.T.Altemose,J.M.Miller
ApplicationofanewalgorithminthedifferentialdiagnosisofwideQRScomplextachycardia
EurHeartJ,28(2007),pp.589600
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[2]
A.E.Buxton,F.E.Marchlinski,J.U.Doherty,B.Flores,M.E.Josephson
Hazardsofintravenousverapamilforsustainedventriculartachycardia
AmJCardiol,59(1987),pp.11071110
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P.Brugada,J.Brugada,L.Mont,J.Smeets,E.W.Andries
AnewapproachtothedifferentialdiagnosisofaregulartachycardiawithawideQRScomplex
Circulation,83(1991),pp.16491659
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[4]
M.E.Herbert,S.R.Votey,M.T.Morgan,P.Cameron,L.Dziukas
Failuretoagreeontheelectrocardiographicdiagnosisofventriculartachycardia
AnnEmergMed,27(1996),pp.3538
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Widecomplextachycardia:continuedevaluationofdiagnosticcriteria
AcadEmergMed,7(2000),pp.769773
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[6]
A.Vereckei,G.Duray,G.Szenasi,G.T.Altemose,J.M.Miller
NewalgorithmusingonlyleadaVRfordifferentialdiagnosisofwideQRScomplextachycardia
HeartRhythm,5(2008),pp.8998
Article|
Correspondingauthorat:DepartmentofEmergencyMedicine,VanderbiltUniversity,131321st
AvenueSouth,312OxfordHouse,Nashville,TN37027,USA.Tel.:+16158756151fax:+1615936
3754.
Copyright2012JapaneseCollegeofCardiology.PublishedbyElsevierIrelandLtd.Allrightsreserved.
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