ABC of clinical electrocardiography by Francis Morris; William Brady; A John Camm

By Francis Morris; William Brady; A John Camm

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Polymorphic ventricular tachycardia Polymorphic ventricular tachycardia has the electrocardiographic characteristics of torsades de pointes but in sinus rhythm the QT interval is normal. It is much less common than torsades de pointes. If sustained, polymorphic ventricular tachycardia often leads to haemodynamic collapse. It can occur in acute myocardial infarction and may deteriorate into ventricular fibrillation. Polymorphic ventricular tachycardia must be differentiated from atrial fibrillation with pre-excitation, as both have the appearance of an irregular broad complex tachycardia with variable QRS morphology (see Chapter 6).

Consequently, this arrhythmia is commonly misdiagnosed as a supraventricular tachycardia. The QRS complexes have a right bundle branch block pattern, often with a small Q wave rather than primary R wave in lead V1 and a deep S wave in lead V6. When the tachycardia originates from the posterior fascicle the frontal plane axis of the QRS complex is deviated to the left; when it originates from the anterior fascicle, right axis deviation is seen. Right ventricular outflow tract tachycardia This tachycardia originates from the right ventricular outflow tract, and the impulse spreads inferiorly.

5 Atrial fibrillation and left bundle branch block. 6 Atrial flutter with left bundle branch block, giving rise to broad complex tachycardia. QRS complex. Aberrant conduction usually manifests as left or right bundle branch block, both of which have characteristic features. The bundle branch block may predate the tachycardia, or it may be a rate related functional block, occurring when atrial impulses arrive too rapidly for a bundle branch to conduct normally. When atrial fibrillation occurs with aberrant conduction and a rapid ventricular response, a totally irregular broad complex tachycardia is produced.

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