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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.

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Wide Complex Tachycardia

Submitted by Dawn on Fri, 10/09/2020 - 14:30

The Patient   A 64-year-old woman has called 911 because she has chest discomfort radiating to her left arm, palpitations, weakness, and a headache.  She had a valve replacement (we do not know which valve) two weeks ago and has a healing incision over her sternum.  She is found sitting in a chair, pale, cool, and diaphoretic. Her blood pressure is 94/palp.  Her pulse rate is 196 bpm and weak. She is afebrile.

ECG #1   This ECG shows a wide-complex tachycardia at 196 bpm.  The QRS complexes are .132 seconds in duration, per the ECG machine. The rate is too fast to appreciate whether there are P waves present.  We did not see the onset of the tachycardia, but with a rate this fast and regular, it is most likely a reentrant rhythm, rather than sinus tachycardia.  An abrupt onset of the rhythm would point to a diagnosis of a reentrant rhythm, either ventricular tachycardia (VT) or paroxysmal supraventricular tachycardia (PSVT). 

There is an important rule in emergency medical care:  a wide-complex tachycardia should be treated as VT until and unless it is proven to be something else.  The most likely alternate interpretation is PSVT with aberrant conduction, which usually takes the form of left or right bundle branch block. Fortunately, the paramedics on this call have a protocol for treating WCT that includes electrical cardioversion for the unstable patient, and amiodarone for the stable patient.  This protocol serves both possibilities, VT and PSVT, well.  The patient’s perfusion status and BP made her borderline in this determination, but she was alert and oriented, so the paramedics opted for administering the amiodarone while they prepared to electrically cardiovert.

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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:

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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.

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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%.

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