Новые ЭКГ-критерии дифференциальной диагностики тахикардий с «широкими» комплексами QRS по типу блокады правой ножки пучка Гиса
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Shlevkov N.B., Salami H.F., Kiktev V.G., Sokolov S.F. New ECG criteria for differential diagnosis of wide QRS complex tachycardias with right bundle branch block pattern. Therapeutic Archive. 2019; 91 (4): 83–89. DOI: 10.26442/00403660.2019.04.000210
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Материалы и методы. По результатам электрофизиологического исследования сердца (ЭФИ) у 111 пациентов (79 мужчин и 32 женщины, средний возраст 53±17 лет) диагностированы источники тахиаритмий с расширенными комплексами QRS по типу БПНПГ. На первом этапе у 58 пациентов проводился ретроспективный анализ 244 особенностей комплексов QRS в 12 отведениях ЭКГ (не менее 20 параметров в каждом отведении ЭКГ), включая 20 больных желудочковой тахикардией (группа «ЖТ»), 24 пациента с наджелудочковой тахикардией с преходящей БПНПГ (группа «НЖТ+БПНПГ») и 14 пациентов с НЖТ с проведением по дополнительным проводящим путям (группа «НЖТ+ДПП»). По результатам ROC- и многофакторного анализов созданы диагностические ЭКГ-алгоритмы. Вторым этапом проводилась оценка точности созданных ЭКГ алгоритмов на проспективной группе из 53 пациентов.
Результаты и обсуждение. ЭКГ-признаками ЖТ с комплексами QRS по типу БПНПГ являлись: 1) наличие зубца Q в отведении II, 2) длительность интервала R(верш.)–S(оконч.) более 100 мс в отведении V5. Среди аберрантных НЖТ признаками наличия предвозбуждения желудочков по ДПП являлись: 1) отсутствие М-образного комплекса QRS в отведении V2, 2) длительность зубца R в отведении I ≥80 мс, 3) отсутствие зазубрины н восходящей части S в отведении avL. Предложенные ЭКГ-алгоритмы позволили диагностировать ЖТ с точностью 83% (чувствительность 100%, специфичность 73%), в то время как точность дифференциальной диагностики аберрантных НЖТ составила 91% (чувствительность 85%, специфичность 96%).
Заключение. Созданные алгоритмы используют новые ЭКГ-критерии для дифференциальной диагностики тахикардий с расширенными комплексами QRS по типу БПНПГ в дополнение к алгоритмам Велленса, Бругада, Гриффит и др.
Ключевые слова: тахикардии с расширенными комплексами QRS, желудочковая тахикардия, аберрация, наджелудочковая тахикардия, антидромная тахикардия, электрокардиограмма, блокада правой ножки пучка Гиса, дифференциальная диагностика, алгоритм.
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Aim. To evaluate standard 12-lead ECG indices for the differential diagnosis of wide QRS tachycardias with right bundle branch block (RBBB) pattern.
Materials and methods. Study analyses the 244 ECG indices in 111 patients (79 males and 32 females, age 53±17 years) with RBBB tachycardias, who underwent electrophysiological studies. First step includes retrospective analysis of QRS characteristics in 20 patients with ventricular tachycardias (VT), 24 pts with aberrant supraventricular tachycardias (SVT+RBBB) and 14 pts with antidromic SVTs (WPW). ROC- and multifactorial analyses were performed to develop diagnostic ECG algorithms. The prognostic accuracy of the algorithms was subsequently evaluated on a prospective group of patients with RBBB tachycardias (n=53).
Results and discussion. ECG criteria of RBBB VTs were: 1) the presence Q-wave in lead II, 2) the duration interval R(peak)–S(end) >100 ms in lead V5. ECG criteria for antidromic SVTs with RBBB were: 1) the duration of the R wave in lead I ≥80 ms, 2) the absence of split (M-sharp) R-waves in lead V2, 3) the absence notch in ascending S wave in lead aVL. The accuracy of the algorhythm for diagnostic of VTs with RBBB was 83% (sensitivity 100%, specificity 73%). The accuracy of the algorhythm for diagnostic of antidromic SVTs with RBBB was 91% (sensitivity 85%, specificity 96%).
Conclusion. The proposed algorithms are based on new ECG criteria for the differential diagnosis of wide QRS complexes tachycardias with RBBB pattern, unlike the previous algorithms.
Keywords: tachycardia with wide QRS complexes, ventricular tachycardia, aberrant supraventricular tachycardia, antidromic tachycardia, electrocardiogram, the right bundle branch block, algorithm.
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1. Coumel P, Leclercq JF, Attuel P, Maison BP. The QRS morphology in post myocardial infarction ventricular tachycardia. A study of 100 tracings compared with 70 cases of idiopathic ventricular tachycardia. Eur Heart J. 1984;5:792-805.
2. Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Am J Cardiol. 1988;61:1279-83.
3. Brugada P, Brugada J, Mont L, Smeets J, Andries EWI. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83:1649-51.
4. Wellens HJ. Electrophysiology: ventricular tachycardia: diagnosis of broad QRS сomplex tachycardia. Heart. 2001;86:579-85.
5. Vereckei A, Duray G, Szenasi G, Altemose GT, Miller JM. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J. 2007;28:589-600. doi: 10.1093/eurheartj/ehl473
6. Datino T, Almendral J, Avila AP, Torrecilla EG, Atienza F, Arenal A. Specificity of electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardia in patients with intraventricular conduction defect. Heart Rhythm. 2013;10:1393-401. doi: 10.1016/j.hrthm.2013.07.006
7. Oreto G, Luzza F, Satullo G, Donato A, Carbone V, Calabrò MP. Wide QRS complex tachycardia: an old and new problem. G Ital Cardiol. 2009;10:580-95.
8. Josephson MB, Zimetbaum P. The tachyarrhythmias. Ed. by DL Kasper, K Brauwald, A Fauci, et al. Harrison’s Principle of Internal Medicine 16th ed. New York: McGiaw-Hill; 2004.
9. Jastrzebski M, Sasaki K, Kukla P, Fijorek K. The ventricular tachycardia score: a novel approach to electrocardiographic diagnosis of ventricular tachycardia. Europace. 2016;8:578-84. doi: 10.1093/europace/euv118
10. Drew BJ, Scheinman MM. ECG Criteria to Distinguish Between Aberrantly Conducted Supraventricular Tachycardia and Ventricular Tachycardia: Practical Aspects for the Immediate Care Seetting. PACE. 1995;18:2194-208.
11. Griffith M, de Belder MA, Linker NJ, Ward DE, Camm AJ. Difficulties in the use of electrocardiographic criteria for the differential diagnosis of left bundle branch block pattern tachycardia in patients with structurally normal heart. Eur Heart J. 1992;13:478-83.
12. Sousa PA, Pereira S, Candeias R, de Jesus I. The value of electrocardiography for differential diagnosis in wide QRS complex tachycardia. Rev Port Cardiol. 2014;33:165-73. doi: 10.1016/j.repc.2013.07.016
13. Wellens HJJ, Brugada P. Diagnosis of ventricular tachycardia from the twelve lead electrocardiogram. Cardiol Clin. 1987;5:511-26.
14. Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5:89-98. doi: 10.1016/j.hrthm.2007.09.020
15. AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018;25;138:e415-e418. doi: 10.1161/CIR.0000000000000615
16. Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017;5:484-92. doi: 10.1016/j.jemermed.2016.09.010
17. Zadionchenko VS, Shekhyan GG, Shchikota AM, Yalymov AA. Differential diagnosis of "wide" tachycardias. Russkii Meditsinskii Zhurnal = Russian Medical Journal. 2012;14:734 (In Russ.).
18. Buxton AE, Marchlinski FE, Doherty JU, Flores B, Josephson ME. Hazards of intravenous verapamil for sustained ventricular tachycardia. Am J Cardiol. 1987;59:1107-10.
19. Garrаtt C, Antoniou A, Ward E, et al. Misuse of verapamil in pre-excited atrial fibrillation. Lancet. 1989;1;367-9.
20. Gulamhusein S, Ko P, Klein GJ, et al. Ventricular fibrillation following verapamil in the Wolff-Parkinson-White syndrome. Am Heart J. 1982;106:145-7.
21. Tchou PJ, Jazayeri M, Avitall B, et al. Wide QRS tachycardias: machanisms, differential diagnosis and acute management. Ed by GV Naccarelli. Cardiac Arrhythmias: A Practical Approach. Mount Kisco, NY: Futura Publishing; 1991. P. 217-41.
22. Kazakov SA, Rachok SM, Rutskaya TA, et al. Differential diagnosis of tachycardias with a wide QRS complex. Part 1. Traditional and new criteria for the differential diagnosis of ventricular and supraventricular tachycardias. Zdravookhranenie = Health Care. 2016;(1):56-9 [In Russ.).
23. Eckardt L, Deneke T. Updated ESC guideline: innovations for the treatment of ventricular arrhythmias and recommendations for prevention of sudden cardiac death. Herzschrittmacherther Elektrophysiology. 2016;27:94-288. doi: 10.1007/s00399-016-0446-2
24. Differential diagnosis, medical tactics). Vestnik Aritmologii = Bulletin of Arrhythmology. 1998;(7):65-73 [In Russ.).
25. Wang PJ, Friedman PL. "Clockwise" and "counterclockwise" bundle branch reentry as mechanism for sustained ventricular tachycardia masquerading as supraventricular tachycardia. PACE. 1989;12;1426-32.
Научно-исследовательский институт клинической кардиологии им. А.Л. Мясникова ФГБУ «Национальный медицинский исследовательский центр кардиологии» Минздрава России, Москва, Россия
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N.B. Shlevkov, H.F. Salami, V.G. Kiktev, S.F. Sokolov
A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russian Federation, Moscow, Russia