Confounding factors leading to misdiagnosing ventricular tachycardia as supraventricular in the emergency room

Jerónimo Farré; José-Manuel Rubio; Eduardo Back Sternick

doi:10.1016/j.ipej.2022.11.002

Confounding factors leading to misdiagnosing ventricular tachycardia as supraventricular in the emergency room

Indian Pacing Electrophysiol J. 2023 Jan-Feb;23(1):1-13. doi: 10.1016/j.ipej.2022.11.002. Epub 2022 Dec 5.

Authors

Jerónimo Farré¹, José-Manuel Rubio², Eduardo Back Sternick³

Affiliations

¹ Madrid Autonomous University, Spain. Electronic address: jfarre@fjd.es.
² Director of the Arrhythmia Unit, Fundación Jiménez Díaz University Hospital and Institute of Health Sciences Research, Madrid, Spain. Electronic address: jmrubio@fjd.es.
³ Arrhythmia and Electrophysiology Department, Biocor Instituto, Rede Dor São Luis, Nova Lima, Minas Gerais, Brazil. Electronic address: eduardosternick@gmail.com.

Abstract

Studies conducted during the last 50 years have proposed electrocardiographic criteria and algorithms to determine if a wide QRS tachycardia is ventricular or supraventricular in origin. Sustained ventricular tachycardia is an uncommon reason for consultation in the emergency room. The latter and the complexity of available electrocardiographic diagnostic criteria and algorithms result in frequent misdiagnoses. Good hemodynamic tolerance of tachycardia in the supine position does not exclude its ventricular origin. Although rare, ventricular tachycardia in patients with and without structural heart disease may show a QRS duration <120 ms. Interruption of tachycardia by coughing, carotid sinus massage, Valsalva maneuver, or following the infusion of adenosine or verapamil should not discard the ventricular origin of the arrhythmia. In patients with regular, uniform, sustained broad QRS tachycardia, the presence of structural heart disease or A-V dissociation strongly suggest its ventricular origin. Occasionally, ventricular tachycardia can present with AV dissociation without this being evident on the 12-lead ECG. Cardiac auscultation, examination of the jugular venous pulse, and arterial pulse palpation provide additional clues for identifying A-V dissociation during tachycardia. This paper does not review the electrocardiographic criteria for categorizing tachycardia as ventricular but rather why emergency physicians misdiagnose these patients.

Keywords: Narrow QRS ventricular tachycardia; Supraventricular tachycardia; Ventricular tachycardia; Ventricular tachycardia misdiagnosis; Wide QRS tachycardia.