ECG criteria to distinguish between aberrantly conducted supraventricular tachycardia and ventricular tachycardia: Practical aspects for the immediate care setting

To reevaluate ECG criteria for distinguishing supraventricular tachycardia (SVT) with aberrant conduction from ventricular tachycardia (VT), 133 wide QRS tachycardias were recorded in patients undergoing invasive electrophysiological (EP) study. Surface ECG leads (standard 12-lead and MCL leads) were compared to EP recordings to provide a standard for correct diagnosis. Criteria from six studies were pooled to select QRS morphology agreed to be highly specific for SVT or VT (specificity, 90%). Some morphological criteria were modified to simplify analysis for the immediate care setting. Results: Although the 12-lead ECG was useful in distinguishing aberrancy from VT, 13 tachycardias (10%) were misdiagnosed or could not be diagnosed. The MCL(1) lead recorded clearly different QRS morphology than lead V-1 in 40% of VT cases and was diagnostically inferior to V-1. Most established criteria were highly specific for a diagnosis, but not very sensitive as individual criteria. Neither a QRS width of > 0.14 seconds nor a monophasic R wave pattern in lead V-1 were valuable in diagnosing VT. Conclusions: In distinguishing SVT with aberrant conduction from VT: (1) Although the 12-lead ECG is valuable, about 1 in 10 wide QRS tachycardias differentiation; (2) tachycardias, > 190 beats/min often do not exhibit unequivocal criteria with which to make a certain diagnosis; (3) multiple leads are required for accurate assessment of QRS width, presence of AV dissociation or VA block, QRS axis, and morphological criteria; and (4) the MCL(1) lead cannot be substituted for V-1 in the use of morphological criteria for VT.