Ventricular Tachycardia in Doubt : Usefulness of Brugada and R Wave Peak Time Criteria

Author : Albertus , M. Setiawan
Upload Date : 19-04-2018

Ventricular tachycardia (VT) commonly occurs in structural heart disease. Myocardial scar from prior infarct is the most common cause of sustained monomorphic VT. Eighty percent of wide complex tachycardia cases are VT. However, choosing simple and concise algorithm to support the diagnosis remains a challenge.

64 y.o male presented with typical angina and hystory of syncope one hour before admission. The patient had no similar history of tachycardia, no pacemaker implantation, ICD or taking any TCA and anti-arrhythmic drugs. In ED : BP 140/70 mmHg, HR 113 bpm, RR 28x/minutes, SaO2 97%. Canon a wave was detected at the jugular veins. A pansystolic murmur was heard at the 5th left intercostal line. Lab : hyperglicemia, normal kidney function and no electrolyte disturbance. ECG reveals sinus rhythm, PR interval 120ms, QRS interval 120ms with ST-Elevation on inferior leads and consecutive runs of 4 PVCs lasting <30 seconds. Diagnosis of STEMI Inferior with nonsustained VT was established. Patient was given aspirin 160 mg, clopidogrel 300 mg, statin, and low-molecular weight heparin. Five hours later, the blood presure suddenly fell to 60mmHg with palpation, the ECG became wide complex tachycardia with regular rhythm while the patient remained awake and had a palpable pulse. Based on Brugada algorithm, the ECG strongly implies VT due to the R to S interval > 100ms in one precordial lead and the presence of AV dissociation. R Wave Peak Time (RWPT) in lead II  ≥ 50 ms (100 ms).

Brugada algorithm has been the most widely used algorithm (sensitivity 89%; specifity 59,2%) while RWPT has the highest specificity among all (specifity 82,7%).  This case should be a reminder for physicians that in patients with STEMI, we should always consider the possibility of VT using appropriate algorithms to avoid its catastrophic consequences.


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