Monday, January 16, 2012

ECG Interpretation Review #35 (SCT - VT - Tachycardia Algorithm - RVOT - Adenosine)

You are given the 12-lead ECG shown in Figure 1 and told it is from a previously healthy 30-year-old man who just presented to the emergency department with new-onset palpitations. No prior ECG is available for comparison. The patient is alert and hemodynamically stable with a BP = 150/90 mmHg. What is the rhythm? Is this rhythm likely to respond to adenosine?
Figure 1 – 12-lead ECG from a 30-year-old man with palpitations.
Is adenosine likely to convert this rhythm? (Figure reproduced from ACLS: Practice Code Scenarios-2014 - Case A).
NOTEEnlarge by clicking on FiguresRight-Click to open in a separate window.
INTERPRETATION: The rhythm is rapid and regular at a rate of ~180/minute. The QRS complex is obviously wide. No P waves are seen. Thus, the rhythm is a regular WCT (Wide-Complex Tachycardia) without clear sign of atrial activity. VT (Ventricular Tachycardia) must be assumed until proven otherwise!
  • As previously emphasized on ECG Blog #23 – VT is by far the most common cause of a regular WCT when there is no sign of atrial activity (accounting for >80% of cases). The bizarre axis deviation during tachycardia in Figure 1 makes diagnosis of VT a virtual certainty.
TREATMENT of Sustained VT: Clinical management of sustained VT depends on the setting in which it occurs. It is easiest to use assessment of hemodynamic status when contemplating how best to proceed: 
  • IF there is No Pulse in association with sustained VT – Treat the same as for ventricular fibrillation (= immediate unsynchronized countershock). 
  • IF there is a pulse, but the patient is hemodynamically unstable (hypotensive, having chest pain, shortness of breath or mental confusion) – there is no time to lose. As a result – immediate synchronized cardioversion is in order. 
  • But IF the patient with sustained VT is hemodynamically stable – then there is at least a moment of time to contemplate options and initiate a trial of antiarrhythmic therapy.
Much has been written about ACLS recommendations for the treatment of sustained VT (See this pdf from Section 07.0 on Known VT excerpted from ( our ACLS-2013-ePub). For the patient who is hemodynamically stable – amiodarone is usually the first antiarrhythmic agent tried. Other medical options for treatment of sustained stable VT include procainamide, lidocaine, magnesium, and beta-blockers (depending on clinical circumstances). Not generally appreciated is the potential role of adenosine in the management of known VT – for WCT of uncertain etiology – and especially for the clinical situation posed by this theoretical case scenario for which adenosine may be the agent of choice.
  • Adenosine is an emergency treatment of choice for supraventricular tachyarrhythmias. One or two doses of the drug is successful in converting over 90% of reentrant PSVT. 
  • Even when adenosine does not convert a supraventricular tachyarrhythmia – it may assist diagnostically as a form of “chemical valsalva” by transiently slowing the ventricular response. This may facilitate recognition of “telltale” atrial activity – thereby allowing definitive diagnosis of the rhythm. 
  • Because of its ultra-short half-life (less than 10 seconds! ) – adverse effects produced by IV adenosine are usually short-lived. As a result – the drug has been used in the management approach to a regular WCT of uncertain etiology. Traditionally, it has been thought that IF the WCT is supraventricular in etiology (SVT with either aberrant conduction or preexisting bundle branch block) – then adenosine is likely to either convert the rhythm or transiently slow the ventricular response enough to allow definitive diagnosis. On the other hand, if the WCT is VT – then adenosine will not be effective (but because of its ultra-short half-life – the drug will almost always be reasonably well tolerated without lasting adverse effect). 
Adenosine-Responsive VT: Recent appreciation of a number of adenosine-responsive forms of VT mandate modification of previous thinking. Although most often associated with RVOT (Right Ventricular Outflow Track) VT – a number of other adenosine-responsive forms of VT have been identified, including forms that are associated with ischemia and fascicular WCT. The proposed mechanism of action of adenosine in these nonreentrant catecholamine-mediated forms of VT is thought to relate to adenosine receptor inhibition of adenylate cyclase, as well as modulation in autonomic tone.
  • RVOT VT is suggested by the finding of VT with LBBB-type precordial lead morphology in association with an inferior axis (with positive QRS complexes in II,III,aVF indicative of a superior origin for the impulse). This ECG picture is seen in Figure 1. Clinical characteristics of RVOT VT are typically similar to that in this case (a patient ~20-40 years old; lack of underlying structural heart disease; precipitation of symptoms with exercise, stress, caffeine intake or other catecholamine-mediated activity).
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BOTTOM LINE: Overall – adenosine-responsive VT makes up a minority of VT cases. That said – determination of the true prevalence of this entity is challenging, and determined in great part by the associated clinical circumstances of the case at hand. This diagnosis should be suspected when a previously healthy young adult presents with a WCT precipitated by exercise, stress, or other catecholamine-mediated activity. This is especially true if the WCT manifests precordial lead LBBB-type morphology in association with an inferior axis (as in Figure 1). However, given the heterogeneous nature of adenosine-responsive VT – other QRS morphologies may certainly be seen. One therefore cannot reliably predict from assessment of the ECG which patients with VT are likely to respond to adenosine.
  • Appreciation of the entity of adenosine-responsive VT provides a rationale for earlier empiric inclusion of adenosine in the treatment approach to both WCT of uncertain etiology as well as for presumed new-onset VT.
  • Adenosine is likely to convert those WCTs due to reentrant PSVT with either aberrant conduction or preexisting bundle branch block. It may also convert a small (but not insignificant) percentage of cases of VT that are adenosine-responsive.
  • Response of a WCT to treatment with adenosine should no longer be taken as reliable indication that the WCT was supraventricular (since it may have been due to an adenosine-responsive form of VT). These patients with WCT that responds to adenosine should be referred for electrophysiologic evaluation of their rhythm disturbance.
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REFERENCES: 
  1. Markowitz SM, Litvak BL, Lerman BB, et al: Adenosine-sensitive VT Right Ventricular Abnormalities Delineated by MRI. Circulation 96:1192-1200, 1997. 
  2. Lerman BB, Belardinelli L, West AG, et al: Adenosine-sensitive Ventricular Tachycardia: Evidence Suggesting Cyclic AMP-mediated Triggered Activity. Circulation 74:270-280, 1986.
  3. Jane-Wit D et al: Ischemic Etiology for Adenosine-Sensitive Fascicular Tachycardia. J Electrocardiol 44(2):217-221, 2011. 
  4. Srivathsan K, Lester SJ, Appleton CP: Ventricular Tachycardia in the Absence of Structural Heart Disease. Indian Pacing Electrophysiol J 5:106-121, 2005. 
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- See ECG Blogs #23 - #24 and #38 
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5 comments:

  1. Great post!
    Working in EMS, your final point is probably the most important to me. I usually don't know who's going to be taking over care of the patient once we arrive at the hospital, so for now, unless I have protocols or med control orders that explicitly tell me to lead with adenosine, I'm not going to. Most of the providers I work with are excellent, but still every few weeks I still have a doc or PA tell me that the 12-lead I've shown them is useless because the patient has a LBBB or pacemaker, so if some of them don't know the Sgarbossa criteria by now, I really don't expect them all to know about adenosine-sensitive V-Tach.

    I think it might have been Dr. Stephen Smith who once emphasized the typically benign nature of adenosine-sensitive V-Tach and that the patients usually go on to have good outcomes. Still, it is certainly not something I understand nearly well enough to warrant setting up a scenario where the patient may not receive adequate follow-up when I can just choose not to use adenosine and avoid that pitfall.

    Just wanted to offer up my perspective from outside the hospital since I know a lot of your readers are prehospital professionals. Thanks for the helpful reviews Dr. Grauer.

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  2. Thanks so much for your comment Vince! I understand the challenge when those occasions arise when you are more aware of certain things than the person who is directing management. I greatly appreciate your perspective. We are all always learning. Glad my post was helpful.

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  3. Thanks a lot for your kind help and contribution

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