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European Heart Journal Advance Access originally published online on July 29, 2008
European Heart Journal 2008 29(19):2351-2358; doi:10.1093/eurheartj/ehn340
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

Rate-related changes in QRS morphology in patients with fixed bundle branch block: implications for differential diagnosis of wide QRS complex tachycardia

Tomás Datino, Jesús Almendral*, Esteban González-Torrecilla, Felipe Atienza, Francisco J. García-Fernández, Ángel Arenal, Leonardo Atea and Francisco Fernández-Avilés

Cardiology Department, Hospital General Universitario, Gregorio Marañón, Doctor Esquerdo 46, Madrid 28007, Spain

Received 3 December 2007; revised 15 June 2008; accepted 8 July 2008; online publish-ahead-of-print 29 July 2008.

* Corresponding author. Tel/Fax: +34 915 868 276, Email: almendral{at}secardiologia.es

See page 2319 for the editorial comment on this article (doi:10.1093/eurheartj/ehn391)

Aims: To analyse QRS morphology in response to rapid atrial pacing (RAP) and supraventricular tachycardia (SVT) in patients with pre-existing bundle branch block (BBB).

Methods and results: We prospectively studied 59 patients in sinus rhythm (SR), with QRS ≥ 120 ms, and no pre-excitation. Trains of RAP were introduced at increasing rates until atrioventricular block. QRS during SR and last QRS complex of each RAP train were compared on the 12-leads. Previously described criteria for minor and major configuration differences were used to identify QRS changes. During RAP minor QRS changes were seen in 22 (37%) and major changes in 23 (39%) subjects. One patient showed major axis shifts and no one showed a change to the contralateral BBB pattern. QRS changes were significantly and independently related to RAP rate and type of BBB (more frequent if right-BBB). Of 14 subjects (24%) with SVT, 13 displayed the same QRS changes during RAP.

Conclusion: In patients with organic BBB, important changes in QRS morphology, except for a change in the contralateral BBB, can appear during RAP and SVT. Thus, in these patients, a change in QRS morphology during tachycardia does not necessarily imply that it is ventricular tachycardia.

Key Words: Tachycardia • Bundle branch block • Diagnosis • Wide QRS complex tachycardia • Electrocardiography


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The QRS configuration during bundle branch block. What has rate got to do with it?
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H. J. Wellens
The QRS configuration during bundle branch block. What has rate got to do with it?
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