Ventricular tachycardia including torsades de pointes and polymorphic ventricular tachycardia

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Ventricular Tachycardia

• Ventricular tachycardia originates from a ventricular focus
• Lasts more than 30 seconds
• Broad QRS complexes: rate of >90 beats/minute

Paroxysmal Ventricular Tachycardia

1. Rapid succession of three or more ectopic beats.
2. Sustained if it lasts longer than 30 seconds.
3. Called incessant if the tachycardia is recurrent and the episodes are interrupted by only a few sinus beats.

EKG Findings

1. Abnormal and wide QRS complexes with secondary ST segment and T wave changes.
   
   • Usual QRS duration is > 0.12 seconds, may be shorter if the ectopic focus is located in the ventricular septum.
   • The secondary ST segment and T wave changes are in a direction that is opposite the major deflection of the QRS.
   • A ventricular rate between 140 and 200 BPM.
   • When the rate is >200 and has a sine wave appearance, it is called ventricular flutter.
   • When the rate is <110 BPM it is called non-paroxysmal VT.
2. A regular or slightly irregular (up to 0.03 seconds) rhythm.
   
3. Abrupt onset and termination.
   
4. AV dissociation.
   
   • Atrial rate slower than ventricular rate.
   • No relationship between atrial activity and ventricular activity.
   • There can be VA conduction.

     1. The RP interval is >0.11 seconds.
     2. Occurs in about 50% of cases.
     3. Uncommon when the ventricular rate is rapid (only 1/7 when the rate was>200).

5. Capture beats.
   
   • Occurs when a supraventricular impulse is conducted and captures the ventricle.
   • They are rare.
6. Fusion beats.
   
   • Rare in VT at a rapid rate.^{[1] [1] [1]}

Torsade De Pointes and Polymorphic VT

Background

1. The peaks of the QRS complexes appear to twist around the isoelectric axis.
2. Polymorphic VT is distinguished from Torsades by the absence of QT prolongation in polymorphic VT.

EKG Findings

1. Paroxysms of VT with irregular RR intervals.
2. A ventricular rate between 200 and 250 beats per minute.
3. Two or more cycles of QRS complexes with alternating polarity.
4. Changing amplitude of the QRS complexes in each cycle in a sinusoidal fashion.
5. Prolongation of the QT interval.
6. Is often initiated by a PVC with a long coupling interval, R on T phenomenon.
7. There are usually 5 to 20 complexes in each cycle.

Clinical Correlation

1. Drugs: quinidine, PCA, norpace, amiodarone, phenothiazines, Tricyclic antidepressants, pentamidine.
   • with quinidine majority of the cases occur within one week of initiation, and with therapeutic levels
2. Electrolyte imbalances: Hypokalemia, hypomagnesemia, hypocalcemia
3. CAD
4. MVP
5. Variant angina
6. Myocarditis
7. Subarachnoid hemorrhage
8. Congenital QT prolongation
9. Liquid protein diets
10. Hypothyroidism
    • because of bradycardia and a prolonged QT syndrome
11. Organophosphate poisoning ^{[1] [1]}

References

v • d • e Electrocardiography
Overview	History of the EKG • EKG interpretation basics • Normal sinus rhythm
EKG Complexes	P wave • QRS complex • ST Segment • T wave • U wave Osborn wave • H wave • K wave • Delta wave NSSTW changes
EKG Intervals	PR Interval • QRS Interval • ST Interval • QT Interval
Conduction System & Bradycardia	Cardiac pacemaker • SA node • AV node• Bundle of His • Purkinje fibers • Sinus bradycardia • First Degree AV Block • Second Degree AV Block • Complete or Third-Degree AV Block • Concealed conduction • AV Junctional Rhythms • LBBB • LAHB • LPHB • RBBB • Trifascicular block
Atrial Arrhythmias	Sinus tachycardia • Premature Atrial Contractions (PACs) • Ectopic Atrial Rhythm • Paroxysmal Atrial Tachycardia (PAT) • Paroxysmal Atrial Tachycardia (PAT) with Block • Multifocal Atrial Tachycardia (MAT) • Atrial Flutter • Atrial Fibrillation • Wandering atrial pacemaker
Ventricular Arrhythmias	Differential Diagnosis of Tachycardia with a Wide QRS Complex • Accelerated Idioventricular Rhythm • Ventricular Parasystole • Premature Ventricular Contractions (PVCs) • Ventricular tachycardia • Ventricular Fibrillation • Sudden cardiac death
EKG Abnormalities in Disease States	Hypertrophy & Dilatation • Right atrial enlargement • Left atrial enlargement • Biatrial enlargement • Left Ventricular Hypertrophy • Right Ventricular Hypertrophy • Biventricular Hypertrophy • Acute myocardial infarction • NSTEMI • STEMI • Right ventricular myocardial infarction • Atrial infarction Pre-excitation Syndromes • Wolff-Parkinson-White Syndrome • Lown Ganong Levine Syndrome • Mahaim Type Preexcitation Cardiomyopathies • Arrhythmogenic Right Ventricular Dysplasia • Dilated Cardiomyopathy • Hypertrophic Cardiomyopathy Drug Effects on the EKG • Adenosine • β-blockers • Digitalis • Quinidine • Procainamide • Disopyramide • Lidocaine • Tocainide and Mexiletine • Phenytoin • Encainide, Flecainide and Propafenone • Amiodarone • Bretylium • Ca Channel Blockers • Phenothiazines • Tricyclic Antidepressants • Lithium Congenital Heart Disease • Dextrocardia • Atrial Septal Defect • Ventricular Septal Defect • Tetralogy of Fallot • Conjoined Twins or Siamese Twins Electrolyte Disturbances • Hyperkalemia • Hypokalemia • Hypercalcemia • Hypocalcemia • Nonspecific Changes Other Heart Diseases • Pericarditis • Myocarditis • Tamponade • Heart Transplantation • Sick Sinus Syndrome • Long QT Syndrome Inherited Disease • Brugada Syndrome Systemic Diseases • CNS Disease • Cardiac Tumors Heart Transplantation • EKG Changes in patient with Heart Transplantation Exogenous Effects • Hypothermia • Chest Trauma • Insect Bites • Electric Injuries
Technical Issues and Potential Errors in Interpretation	Artifacts • Lead Placement Errors • The EKG in a Patient with a Pacemaker

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Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .