Tag Archives: elettrocardiografy

Aberranza od ectopia nelle tachiaritmie a complessi larghi: un metodo “one step” per fare diagnosi.

25 Set

Vtach question mark

La diagnosi elettrocardiografica delle tachiaritmie a complessi larghi pone spesso il medico d’urgenza di fronte ad un dilemma culturale e clinico.

La localizzazzione del foco ectopico o il riconoscimento dell’aberranza infatti non sono un mero esercizio accademico ma un’informazione determinante per il proseguio del percorso terapeutico.

Molti metodi che utilizzano criteri clinici e morfologici sono stati indicati come adiuvanti nella diagnosi in caso di tachiaritmie a complessi larghi.

I criteri clinici si sono dimostrati nel corso degli anni poco affidabili ed addirittura fuorvianti.

I criteri morfologici hanno specificità e sensibilità tra di loro diverse.

  • Brugada Algorithm: SN 89%, SP 59.2%
  • Vereckei aVR Algorighm: SN 87.1%, SP 48%
  • Bayesian Algorithm: SN 89%, SP 52%
  • Griffith (Bundle Branch Block) Algorithm: SN 94.2%, SP 39.8%

Tra tutti quello che sicuramente ha riscosso più fortuna è il metodo di Brugada.



Attribution: ALIEM Academic Life In Emergency Medicine

Il metodo di Brugada è sicuramente poco maneggevole nel setting dell’emergenza, perchè è multi-step e quindi di difficile memorizzazione ed applicabilità.

Il metodo R-Wave Peak Time (RWPT) è sicuramente un metodo di semplice uso e di facile memorizzazione.

E’ one-step e si applica in derivazione D2 che è la derivazione più comunemente usata quando facciamo diagnosi di ritmo dal monitor-defibrillatore

Consiste nel misurare l’intervallo tra la fine dell’isoelettrica e il primo cambiamento di direzione dell’asse del QRS.


Attribution: ECGpedia.org

La diagnosi di Tachcicardia Ventricolare può essere posta quando questo intervallo ≥ 50 ms.

Il criterio dimostra una buona sensitività e specificità, anche se è stato finora validato su un campione limitato di pazienti

 Sensitivity  93.2% 
 Specificity  99.3% 
 Positive Predictive Value  98.2% 
 Negative Predictive Value       93.3% 

Quello che sembra l’uovo di colombo  nelle tachiaritmie a complessi larghi in effetti introduce un criterio interessante, ma pone la difficile condizione di dover calcolare con precisione la fine dell’isoelettrica ed il cambio di direzione dell’asse del QRS, per poterlo applicare correttamente.

Bottom line:

Aberranza o ectopia?

  • I criteri clinici sono inaffidabili e fuorvianti.

  • I criteri morfologici classici e multi-step sono difficilemtne applicabili in emergenza.

  • Il metodo R-Wave Peak Time (RWPT) è affidabile e riproducibile.

  • E’ auspicabile una misurazione elettronica del criterio da esso utilizzato per renderlo applicabile.

  • Sono sicuramente necessari studi che lo validino su un campione più ampio di pazienti.


  1. P. Brugada, J. Brugada, L. Mont, J. Smeets, and E.W. Andries, “A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex.”, Circulation, 1991.
  2. A. Vereckei, G. Duray, G. Szénási, G.T. Altemose, and J.M. Miller, “Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia.”, European heart journal, 2007.
  3. E.W. Lau, R.K. Pathamanathan, G.A. Ng, J. Cooper, J.D. Skehan, and M.J. Griffith, “The Bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia.”, Pacing and clinical electrophysiology : PACE, 2000.
  4. M.J. Griffith, C.J. Garratt, P. Mounsey, and A.J. Camm, “Ventricular tachycardia as default diagnosis in broad complex tachycardia.”, Lancet, 1994.
  5. L.F. Pava, P. Perafán, M. Badiel, J.J. Arango, L. Mont, C.A. Morillo, and J. Brugada, “R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias.”, Heart rhythm : the official journal of the Heart Rhythm Society, 2010.
  6. T. Datino, J. Almendral, P. Avila, E. González-Torrecilla, F. Atienza, A. Arenal, and F. Fernández-Avilés, “Specificity of electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardia in patients with intraventricular conduction defect.”, Heart rhythm : the official journal of the Heart Rhythm Society, 2013.

Dolore epigastrico in diabetica

28 Mag

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Dizziness and amyloidosis in prehospital.

4 Gen

68 years old male referring dizziness and lighthead. Denies chest pain.

Pale cold sweating is laying on bed. Chest and abdominal examination are negative. Cardiac examination reveals arrithmiyc tones and free pauses. No smoking no diabetes.

His past history is positive for cardiac amyloidos  (proteinuria Bence Jones k)  triple A surgically corrected many years ago. Hypertension and AFib farmacologiccally cardioverted 1 year ago.  He is in treatment with Propafenone 150×4, Ramipril and Warfarin. No smoking no diabetes.

This morning ha did a routine control ECG and echo. All the parameters where fine. The documentation is not with him right now so is not possible a proper confrontation with the actual findings.

Vital signs:

BP is 70/50, satO2 room air 98%.

The 12 leads EKG is shown below

12 der

and a longer monitor recording….


Which are the EKG findings?

When the patient is invited to stand refers presyncopal signs and tends to faint. BP drops and the skin become pale and sweaty

Which is the racommended management?

Blood exams are normal except TnI tha is slightly elevated (0,23) and the INR is 3

Which is your diagnosis?


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