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Dr A Röschl's picture

HOLTER ECG: FAST VT, ATP, ICD SHOCK

Submitted by Dr A Röschl on Thu, 04/24/2025 - 01:13

Sometimes a single Holter ECG can tell a whole story. Here we see a single-channel ECG, each line representing about 30 seconds.
The ECG is from a 56-year-old man with severe ischemic cardiomyopathy who had an ICD implanted a few months ago due to recurrent ventricular tachycardia.
The explanation of what can be seen on this ECG can be found on the 2nd image.
Interestingly, the patient did not notice these events, they had occurred at night during sleep.

Dr A Röschl's picture

POLYMORPHIC VT

Submitted by Dr A Röschl on Tue, 01/14/2025 - 02:03

What can we learn from this 3-channel ECG?
A sinus rhythm can be seen in the left half of the image, which merges into a ventricular tachycardia on the right. The QRS complexes of the VT change their shape and polarity, this is called polymorphic.
The question is: can this be called TdP (Torsade de Pointes) tachycardia or not? The clear answer is: no! A polymorphic VT may only be called TdP if there is a prolonged QT/QTc duration in the native rhythm. This is obviously not the case here. Therefore, the term polymorphic VT is retained here

Dr A Röschl's picture

VENTRICULAR TACHYCARDIA, ATRIAL FIBRILLATION AND ABERRANT CONDUCTION

Submitted by Dr A Röschl on Fri, 11/15/2024 - 01:06

It is not uncommon for several different abnormal changes to occur simultaneously in an ECG, as in this Holter ECG strip. The explanation of the visible ECG changes can be found in the 2nd image

Dr A Röschl's picture

NONSUSTAINED VT

Submitted by Dr A Röschl on Mon, 09/23/2024 - 02:51

Extract from a Holter ECG, 2 continuous strips, recorded at 25 mm/s. At the top you can see a broad complex tachycardia without recognizable P waves, which ends spontaneously after 2 beats in the lower section. This is a ventricular tachycardia (VT). The very first beat in the 1st strip is most probably a fusion beat. After the end of the VT in the 2nd strip, a narrow QRS complex appears, here you can also recognize that atrial fibrillation is present.

Dawn's picture

Wide Complex Tachycardia

Submitted by Dawn on Fri, 05/24/2024 - 20:18

The Patient:   A 78-year-old woman called emergency responders because she had palpitations. She was alert and oriented.  Her BP was reported as being “stable”.  We do not have information about her past medical history.  We will update this post if we receive information about her outcome. 

ECG Number 1, 11:57 a.m.:  There is a wide-complex tachycardia at a rate of about 230 bpm.  The QRS is .15 seconds (150 ms).  The QRS frontal plane axis is leftward. P waves are not readily seen, but the computer gives a P axis and PRI.  The PRI given is taken from Lead II, which, along with V5, does have P waves. In the other leads, the P waves are buried in preceding T waves.  This photo shows an ECG that is not lying flat, so it is difficult to line up the complexes.  Normally, it helps to look at the leads above or below to determine where waves begin and end, as all three channels are run simultaneously. The QRS complexes have a “typical” left bundle branch block morphology, with an rS complex in V1 and a monophasic R wave in Leads I and V6.  The T waves are “discordant”, they are in the opposite direction from the QRS complexes, which is typical of LBBB. 

ECG Number 2, 12:05 p.m.:   This is a rhythm strip recording a synchronized shock at 100 joules, resulting in conversion of the WCT to a narrow complex, irregular rhythm.  It appears that there is a P wave before every narrow QRS, but artifact prevents proper evaluation. 

Dawn's picture

Regular Really Wide QRS Tachycardia

Submitted by Dawn on Wed, 03/06/2024 - 16:00

The Patient:    Unfortunately, this is an old tracing, and we do not have patient information, other than the list of medications the patient has been taking, (Lasix, Capoten, Ntg, and Procardia). Lasix (furosemide) is a potassium – wasting diuretic.  Capoten (captopril) is an ACE inhibitor.  Ntg is presumably sublingual nitroglycerine used for angina. Procardia (nifedipine) is a calcium-channel blocker.  So, we can assume the patient was probably being treated for angina, heart failure, and hypertension.

 The ECG:  The first impression is that is a regular WIDE COMPLEX TACHYCARDIA.  The ventricular rate is 100 bpm (Starts a little faster at the beginning at 106, then is 100 by the end).  The QRS duration is about 250 ms (.25 seconds) – VERY WIDE.  There appear to be P waves outside the QRS complexes in V1 and aVL, but probably buried in the ST-T of other leads. 

 We were all taught to treat all wide complex tachycardia (WCT) as VENTRICULAR TACHYCARDIA (VT) until proven otherwise.  This is a very good rule, especially in an emergency setting. It pays to take a moment to consider the possibility of REGULAR REALLY WIDE COMPLEX TACHYCARDIA (RRWCT) before making a treatment decision.

 An extremely wide QRS can occur because of a number of very concerning reasons, most involving blockade of the sodium channels.  Included in this category are:

Dr A Röschl's picture

VENTRICULAR TACHYCARDIA WITH SUCCESSFUL ATP

Submitted by Dr A Röschl on Thu, 12/21/2023 - 11:15

If ventricular tachycardia occurs in an Implantable Cardioverter Defibrillator (ICD) wearer, the ICD can combat this with 2 different forms of therapy, provided these are activated (which can be done using a programming device). First, the ICD attempts to override the tachycardia. The fastest pacemaker gets control of the heart. If this is not successful, the defibrillator function is used. Here you can see the limb leads. Initially there is a relatively slow ventricular tachycardia.

Dr A Röschl's picture

SUSTAINED VENTRICULAR TACHYCARDIA

Submitted by Dr A Röschl on Wed, 12/20/2023 - 10:11

A sustained VT is a ventricular rhythm with a frequency of more than 100 beats per minute that usually lasts at least 30 seconds or must be terminated earlier due to hemodynamic instability.
We see here a wide complex tachycardia with a frequency of approx. 105-110 beats per minute that lasts for a good minute. It begins with a premature QRS complex without a premature P wave. The short VT after the end of the sustained ventricular tachycardia with the same QRS morphology also indicates a ventricular origin of this arrhythmia.

Dr A Röschl's picture

Ventricular Tachycardia. Unsuccessful Antitachycardia Pacing in an ICD Patient

Submitted by Dr A Röschl on Mon, 12/18/2023 - 10:48

If ventricular tachycardia occurs in an Implantable Cardioverter Defibrillator (ICD) wearer, the ICD can combat this with 2 different forms of therapy, provided these are activated (which can be done using a programming device). First, the ICD attempts to override the tachycardia. The fastest pacemaker gets control of the heart. If this is not successful, the defibrillator function is used. Here you can see the limb leads. Initially there is a relatively slow ventricular tachycardia with a heart rate of approx. 125 bpm.

Dr A Röschl's picture

Ventricular Tachycardia

Submitted by Dr A Röschl on Tue, 10/24/2023 - 05:34

There are several differential diagnoses in the presence of broad-complex tachycardia. The most common cause of wide-complex tachycardia is ventricular tachycardia. In 2nd place is sinus tachycardia/supraventricular tachycardia with aberrant conduction or preexisting bundle branch block.

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