Pt admitted
due to SOB due to CHF. Is this accelerated idioventricular rhythm/ventricular
tachycardia (AIVR/VT) or aberrancy?
In patients with baseline sinus
rhythm, it is easy to identify VT from aberrancy. There are 3 basic rules.
First, when the run of WCT is preceded by a premature P wave (often the
P wave has a different morphology), then it is SVT with aberrant conduction. Second, if the WCT is preceded by a
regularly (not prematurely) occurring sinus P wave (the PR
interval is shorter than that of normally conducted sinus beats), it is
ventricular tachycardia. Third, if the WCT is not preceded by a P wave,
it is ventricular tachycardia. In this case, there is a regular sinus P wave (red
arrow) with a PR shorter than that during normally conducted sinus beats. So,
this is an IAVR/VT.
The second evidence for
interpreting this wide QRS rhythm is AIVR/VT is the presence of fusion beats
(black arrows) on the bottom strip. The morphology of those 2 beats are
INTERMEDIATE between sinus beats and ventricular ectopic beats. This means that
the ventricles are depolarized both by
the ectopic ventricular impulse and a supraventricular impulse (sinus beat).
The third
evidence that this is VT is the presence of R>R' or the "rabbit
ear" sign in the V lead.
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