Criteria

Four main diagnostic possibilities

Brugada Criteria
SN 66%, SP 98% SN 82%, SP 98%

SN 21%, SP 100%

SN 98.7%, SP 96.5%

Circulation 1991;83:1649-1659

Brugada Criteria

Brugada Criteria

R only

S only

Brugada Criteria

RS complexes present -> go to step 2

Brugada Criteria

Brugada Criteria

Does it look like a classic BBB?

Quick Method

- RBBB : Lead I terminal broad S wave : V1 rsR or notched monophasic R with notching on ascending limb of R wave - LBBB : Lead I monophasic R only! : V1 : dominant S wave with rapid, un-notched descending limb
Evans, G.T. Practical ECG interpretation, 1998

Does it look like a classic BBB?

Griffith Method : Three Questions

- For RBBB-type complexes : Is there an rSR morphology in V1? : Is there an RS complex in V6 (small septal q OK)? : Is the R/S ratio in V6 > 1? - For LBBB-type complexes : Is there an rS or QS complex in V1 and V2? : Is the onset of the QRS to the nadir of the S in V1 < 70ms? : Is there an R wave in lead V6 without a Q? - Any No result in a default to VT - For VT : sensitivity ~ 90%; specificity ~ 75%
Griffith et al, Lancet 1994;343:386-388

Brugada Criteria

Smooth Monophasic R wave

qR pattern

Taller left rabbit ear (=Marriotts sign)

Brugada Criteria

QS waves in V6

R/S ratio < 1 in V6 (in LAD)

Brugada Criteria

QS waves in V6

Josephsons sign Brugadas sign

qR complex in V6

Vereckei Algorithm
SN 10.1%, SP 100% SN 39.6%, SP 97.1%

SN 74.7%, SP 83.3%

SN 70%, SP 89.4%

Andrs Vereckei et al, Eur Heart J 2007;28:589-600

Vereckei Algorithm

Vereckei Algorithm

Vereckei Algorithm

Vereckei Algorithm

The vi is measured in that lead where a bi- or multiphasic QRS complex is present and the initial ventricular activation is the fastest, and in that particular lead that QRS complex is chosen for the measurement of vi and vt where the onset and end of the QRS are clearly visible.

Vereckei Algorithm

New aVR Algorithm

SN 38.9%, SP 98.2% SN 28.8%, SP 91.8%

SN 19.9%, SP 95%

SN 90.7%, SP 87.5%

Andrs Vereckei et al, Heart Rhythm 2008;5:89-98

New aVR Algorithm

Hypothesized reasons for using aVR

- During SVT w/ BBB, the initial rapid septal activation and the later main ventricular activation wavefront move away from lead aVR, creating a negative QRS complex in lead aVR ; Exception to this generalization is occurs in inferior myocardial infarction where there is the loss of the initial inferiorly directed forces creating an initial r wave (rS complex) during NSR or SVT - Because an initial dominant R wave in aVR is incompatible w/ SVT, its presence suggest VT, typically originating from the inferior or apical region

New aVR Algorithm

Useful for detecting VT originating from sites other than

the inferior or apical wall, but would not show an initial R wave in aVR - Would rather show a slow, initial upward vector of variable size pointing toward aVR even if the main vector of the VT points downward and creates a predominately negative QRS in lead aVR

- Exceptions would be VT originating from the most basal sites of the interventricular septum or free wall

New aVR Algorithm

New aVR Algorithm

Sasaki Criteria
Step 1: Initial R in aVR?

Kenichi Sasaki(Hirosaki Univ), Circulation 2009;120:S671

Step 2: In any precordial lead, is the interval from onset of R-wave to the nadir of the S 100 msec (0.10 sec)? Step 3: Initial r or q 40 ms in any lead?

Sasaki Criteria

Circulation 2009;120:S671

SN & SP for VT diagnosis : 86% and 67% by Brugada algorithm, 76% and 86% by Vereckei algorithm, and 86% and 53% by aVR algorithm AV dissociation had a low sensitivity (7%) and the assessment of bundle branch block morphology showed innegligible interobserver variation (10 to 20% by 3 independent observers). The step with sensitivity 30% and specificity 90% for diagnosing VT included longest RS 100 msec (sensitivity, 37%; specificity, 97%), initial R in aVR (39% and 100%), and Vi/Vt 1.0 (49% and 90%) Evaluating Vi/Vt 1.0 indicative of slow initial ventricular activation in VT is complicated. We measured the duration of the initial r or q of any lead of WCTs and validated it. The duration was 5527 msec in VT and 275 msec in SVT (P <0.05). Receiver operating curve revealed 40 msec as a cutoffpoint which showed 86% sensitivity and 97% specificity for diagnosing VT, both of which were greater than those of Vi/Vt 1.0. The accuracy of this new algorithm (86%) was superior to those of Brugada (79%), Vereckei (79%) and aVR (75%) algorithms (all P<0.05).

Josep Brugada et al, Heart Rhythm 2010;7:922

Ultrasimple Brugada criterion

R wave peak time in Lead II 50ms (SN 93.2%, SP 99.3%)

Ultrasimple Brugada criterion

R wave peak time in Lead II 50ms (SN 93.2%, SP 99.3%)

Ultrasimple Brugada criterion

R wave peak time in Lead II 50ms (SN 93.2%, SP 99.3%)

Specificity of the Previously Proposed ECG Criteria

Alberca T et al, Circulation 1997;96:3527-3533

Several electrocardiographic features that increase the likelihood of VT

Very broad complexes (>160ms)

- In RBBB-like WCT, duration > 140 msec suggests VT - In LBBB-like WCT, duration > 160 msec suggests VT - QRS duration > 160 msec is a strong predictor of VT regardless of BBBM ; Except in cases of SVT w/ an AV accessory pathway and the presence of drugs capable of slowing intraventricular conduction (such as class 1a or class 1c or amiodarone) - QRS duration < 140 msec does not exclude VT ; VT originating from the septum or w/ in the His-Purkinje system

Several electrocardiographic features that increase the likelihood of VT

Positive or negative concordance throughout the chest leads (no RS

complexes) (90% specificity for VT) - positive : all entirely positive w/ tall, monophasic R ; most often d/t VT but can also occur in rare cases of antidromic AVRT w/ a left posterior accessory pathway - Negative concordance All entirely negative w/ deep monophasic QS complexes

Concordance

Antidromic AVRT w/ a left posterior accessory pathyway

Negative Concordance & Northwest axis

Positive Concordance & RBBBM

Positive Concordance

Several electrocardiographic features that increase the likelihood of VT

Capture beats & Fusion beats
V-A conduction Echo Beats

Fusion beat during SVT

V-A conduction

Echo Beat

Several electrocardiographic features that increase the likelihood of VT

Extreme axis deviation (northwest axis)
RBBB with LAD > -30 (Post facicular VT) LBBB with RAD > +90(RVOT VT)

RBBB with LAD

LBBB with RAD

Quiz 1.

Quiz 1.
AVNRT with LBBB
Typical LBBB morphology No positive Brugada criteria

Quiz 2.

Quiz 2.
Monomorphic VT
Although there is a broad complex tachycardia (HR>100,

QRS>120), the appearance in V1 is more suggestive SVT with aberrancy, given that the complexes are not that broad(<160 ms) and the right rabbit ear is taller than the left. However, on closer inspection there are signs of AV dissociation, with superimposed P waves visible in V1. Also, the presence of a northwest axis and an R/S ratio < 1 in V6 (tiny R wave, deep S wave) indicate that this is VT.

Quiz 3.

Quiz 3.
Sinus tachycardia with incomplete RBBB
P waves are visible before each QRS complex There is a typical RBBB morphology with a RSR complex

in V1 and wide S wave in the lateral leads I, V5-6. In contrast to the previous example, there is a dominant R wave in V6 (RS ratio > 1), which is much more typical of RBBB QRS complexes are only slightly prolonged (110 ms), making this an incomplete RBBB. Q waves and T-wave inversions in III and aVF suggest prior inferior infarction.

Quiz 4.

Quiz 4.
Tricyclic antidepressant toxicity
QRS complexes are very broad (~200ms) however,

unlike with VT most of the broadening is in the terminal portion of the QRS (this can be best appreciated in leads V3-6 where narrow R waves are followed by massively broad and deep S waves). There are no positive Brugada criteria in particular, the RS interval is < 100 ms. No P waves can be seen

Quiz 5.

Quiz 5.
AVRT
5 year-old boy This is the one rhythm that may be impossible to

distinguish from VT In this case the main clue is the history more thant 95% of broad complex tachycardias in children are SVT with aberrancy

Quiz 6.

Quiz 6.
Rapid ventricular paced rhythm
There are obvious pacing spikes before each QRS

complex Ventricular paced rhythms have features in common with other ventricular rhythms in this case the ECG demonstrates negative concordance in V1-6, initial R wave > 40 ms in V1, RS interval > 70 ms in V1, QS complex in V6

Vereckei Algorithm

Vereckei Algorithm