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Dawn's picture

Instructors' Collection ECG: Ventricular Tachycardia With PVCs

Submitted by Dawn on Thu, 10/30/2025 - 17:15

The Patient:   This ECG and rhythm strip are from a man in his early sixties.  He was in his cardiologist’s office, complaining of a very rapid heart rate and weakness for several hours. He was standing, and denied pain, shortness of breath, or dizziness.  The vital signs were not shared with us, but the patient was warm and dry, alert and oriented, and ambulatory. We are told that he has an unspecified myopathy and an automatic implanted cardioverter/defibrillator (AICD).

 The 12-Lead ECG:  There is a wide complex (0.174 sec.) tachycardia (WCT) at 162 bpm. The rhythm is slightly irregular, triggering an interpretation of “atrial fibrillation” by the machine.  The computer also suggested right bundle branch block and anterior fascicular block (bifascicular block).  I do not agree with this.  I see a WCT that does not have the typical QRS pattern of RBBB or bifascicular block.  There is an underlying REGULAR rhythm, with occasional premature beats that resemble, but are not identical to, the regular beats. (See rhythm strip included).  

 This rhythm is V Tach.  Often, especially in an emergency setting, V Tach is a re-entrant tachycardia, characterized by a sudden onset and offset and a fast, regular rhythm.  In this case, the V Tach is interrupted every 3-5 beats by a PVC.  This tells us that the V Tach is due to increased automaticity or triggered activity, as a PVC would abolish the re-entry cycle.  The PVCs look very similar to the “regular” V Tach beats, but are not exactly the same.  So, the PVCs are coming from a focus very near the origin of the V Tach.  This regular rhythm with frequent PVCs is easier to appreciate on the long rhythm strip provided, which rules out atrial fibrillation.

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 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

VT or SVT? Here, Both!

Submitted by Dr A Röschl on Sun, 07/30/2023 - 02:07

Complex ECGs like this one have to be approached systematically. Firstly, we can see a normal sinus rhythm. A is the first beat of a wide complex tachycardia. This must be a ventricular tachycardia. Although there is a P-wave before the first beat of the tachycardia, it is not premature. Therefore, there is no SVT with aberrant conduction. The first beat of the tachycardia looks different from the subsequent beats because there is a fusion beat present. The VT conducts 1:1 back to the atria (a small negative P-wave can be seen at the end of the QRS complex in V1).

Dr A Röschl's picture

Ventricular Tachycardia After Inferior Myocardial Infarction

Submitted by Dr A Röschl on Wed, 07/26/2023 - 06:20

76-year-old man, with a history of inferior wall myocardial infarction. He experiences recurrent episodes of brief palpitations, often lasting only 5-15 seconds. In this ECG, at the beginning, the last part of a wide-complex tachycardia is visible. After 2 sinus beats, another wide-complex tachycardia begins (with the same QRS configuration).

Dawn's picture

Wide Complex Tachycardia

Submitted by Dawn on Fri, 05/01/2020 - 16:19

The Patient:   The details of this patient’s complaints and presentation are lost, but we know he was a 66-year-old man who was being treated in the Emergency Department. His rhythm went from sinus tachycardia with non-respiratory sinus arrhythmia to multi-focal atrial tachycardia (MAT) to wide-complex tachycardia. The WCT lasted a few minutes and spontaneously converted to an irregular sinus rhythm.

Wide-complex tachycardia:  Ventricular tachycardia or aberrantly-conducted supraventricular tachycardia?  When confronted with a wide-complex tachycardia, it can be very difficult to determine whether the rhythm is ventricular or supraventricular with aberrant conduction, such as bundle branch block. The patient’s history and presentation may offer clues.  It is very important, if the patient’s hemodynamic status is at all compromised (they are “symptomatic”), the WCT should be treated as VENTRICULAR TACHYCARDIA until proven otherwise.  

There have been many lists made of the ECG features that favor a diagnosis of ventricular tachycardia. Here are two such lists:  Life In The Fast Lane, and National Institute of Health.

The ECG:  This ECG shows a regular, fast, wide-QRS rhythm.  The rate is 233 bpm.  It had a sudden onset and sudden offset (not shown on this ECG), and the rhythm lasted about 3-5 minutes. The patient felt the change in rate, but did not become hypotensive or unstable.  Some features that relate directly to the most commonly-referenced VT vs. SVT charts are:

Dawn's picture

ECG Basics: Ventricular Tachycardia

Submitted by Dawn on Wed, 12/20/2017 - 15:00

V tach is identified by:  wide QRS complexes (>.12 seconds), rate faster than 100 bpm.  In MONOMORPHIC V tach, all QRS complexes look alike.  There are other mechanisms of wide-complex tachycardia, but they can be difficult to differentiate from a single rhythm strip.  All WCT should be treated as V tach until proven otherwise.

Dawn's picture

Ventricular Tachycardia In A Patient With Myopathy

Submitted by Dawn on Tue, 12/19/2017 - 23:15

These two ECGs are from a 77-year-old woman who was complaining of palpitations and mild shortness of breath.  She stated a history of atrial fibrillation.  She was alert, with a systolic BP over 120.  At the hospital, she was found to have cardiomyopathy, resulting in global hypokinesis. She also had significant coronary artery narrowing in her left main, left anterior descending, and circumflex, which were treated with coronary artery bypass graft surgery.

The first ECG was taken on arrival of the EMS crew at the patient’s home.  It shows ventricular tachycardia, rate 226 bpm, All WCTs should be considered to be ventricular tachycardia until proven otherwise.  While WCT can sometimes be difficult to definitively diagnose in the field, this ECG has many features which favor the diagnosis of VT, including:

·         An extremely wide QRS (I measure .24 sec., the machine measures .368 sec.).

·         An extreme left axis deviation (aVF is all negative).

·         Absence of either RBBB or LBBB pattern, with a  completely negative QRS in V6.  This all negative V6 places the liklihood of the rhythm being VT to about 100%.

Dawn's picture

ECG Basics: Torsades Cardioverted

Submitted by Dawn on Fri, 12/20/2013 - 13:08

These two strips are from one patient who was electrically cardioverted twice in a few minutes.  The original reason for the cardioversion was Torsades de Pointes, a type of polymorphic ventricular tachycardia associated with a long QT interval.  For more information about TDP, go to this LINK.  It is a bit difficult to comment on the patient's post-cardioversion rhythm, because so little of it is shown.  It appears to be sinus, with a wide QRS.  The QT interval appears slightly prolonged at .44 sec, but it is not known what the QT interval is corrected to a rate of 60/min.  TDP is often seen with QT intervals greater than 600 ms (.6 seconds).  Also THESE STRIPS ARE NOT SIMULTANEOUS, they were taken two minutes apart.  In the first one, the P waves and T waves look so much alike, they could all be P waves.  They do not "march out".  It is necessary to get a long strip, preferably in multiple leads, and a 12-Lead ECG, to properly evaluate the rhythm post-cardioversion. 

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