Usefulness of ST-segment elevation in lead aVR during tachycardia for determining the mechanism of narrow QRS complex tachycardia

doi:10.1016/j.amjcard.2003.08.051

The American Journal of Cardiology

Volume 92, Issue 12, 15 December 2003, Pages 1424-1428

https://doi.org/10.1016/j.amjcard.2003.08.051 Get rights and content

Abstract

In the present study, we analyzed ST-segment elevation in lead aVR during tachycardia to differentiate the narrow QRS complex tachycardia. A total of 338 12-lead electrocardiograms during narrow QRS complex tachycardia were analyzed. Each patient underwent a complete electrophysiologic study. There were 161 episodes of atrioventricular nodal reentrant tachycardia (AVNRT), 165 episodes of atrioventricular reciprocating tachycardia (AVRT), and 12 episodes of atrial tachycardia (AT). The prevalence of aVR ST-segment elevation was 71% for AVRT, 31% for AVNRT, and 16% for AT. For ST-T changes in different leads, logistic regression analysis showed aVR ST-segment elevation was the only significant factor to differentiate the types of narrow QRS complex tachycardia (p <0.001 for AVRT and AVNRT; p = 0.02 for AVRT and AT). The sensitivity, specificity, and accuracy of aVR ST-segment elevation to differentiate AVRT from AVNRT and AT were 71%, 70%, and 70%, respectively. Among 117 episodes of AVRT with aVR ST-segment elevation, there were 76 (65%) left side, 23 (20%) right side, 14 (12%) posterior septal, and 4 (3%) antero- and mid-septal accessory pathways (p = 0.002). In conclusion, aVR ST-segment elevation during narrow QRS complex tachycardia favors the atrioventricular reentry through an accessory pathway as the mechanism of the tachycardia.

Section snippets

Electrocardiographic analysis

A total of 338 12-lead electrocardiograms recorded during paroxysmal supraventricular tachycardia at the time of invasive electrophysiologic studies were analyzed. The inclusion criterion was the presence of a regular narrow QRS complex (<0.11 second) tachycardia with a 1:1 ratio of atrioventricular activity.3 Exclusion criteria were poor isoelectric line recording of 12-lead electrocardiograms during tachycardia, atrial flutter, atrial fibrillation, right and left bundle branch block patterns,

Results

There were 161 episodes of AVNRT, 165 of AVRT, and 12 of AT (right atrial origin). The heart rate during tachycardia was highest in the AVRT group. The IAAT was significantly longer in the AVRT group than that in the AVNRT group (Table 1). There were 169 electrocardiograms with aVR ST-segment elevation, 157 with ST-T changes in inferior leads, and 75 with ST-T changes in precordial leads. The prevalence of aVR ST-segment elevation was 71% for AVRT, 31% for AVNRT, and 16% for AT (p <0.001). The

Discussion

The lead aVR has been largely ignored in that most electrocardiographers consider this lead as giving reciprocal information from the left lateral side.1, 10 Therefore, standard 11-lead electrocardiograms rather than 12-lead electrocardiograms are used by most interpreters.10 However, several studies used the aVR ST-segment elevation during acute myocardial infarction to identify coronary artery lesions.11, 12, 13, 14 Ischemia of the basal part of the interventricular septum causes ST-segment

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Identification of supraventricular tachycardia mechanisms with surface electrocardiograms using a convolutional neural network
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It remains difficult to definitively distinguish supraventricular tachycardia (SVT) mechanisms using a 12-lead electrocardiogram (ECG) alone. Machine learning may identify visually imperceptible changes on 12-lead ECGs and may improve ability to determine SVT mechanisms.
We sought to develop a convolutional neural network (CNN) that identifies the SVT mechanism according to the gold standard of SVT ablation and to compare CNN performance against experienced electrophysiologists among patients with atrioventricular nodal re-entrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT), and atrial tachycardia (AT).
All patients with 12-lead surface ECG during sinus rhythm and SVT and had successful SVT ablation from 2013 to 2020 were included. A CNN was trained using data from 1505 surface ECGs that were split into 1287 training and 218 test ECG datasets. We compared the CNN performance against independent adjudication by 2 experienced cardiac electrophysiologists on the test dataset.
Our dataset comprised 1505 ECGs (368 AVNRT, 304 AVRT, 95 AT, and 738 sinus rhythm) from 725 patients. The CNN areas under the receiver-operating characteristic curve for AVNRT, AVRT, and AT were 0.909, 0.867, and 0.817, respectively. When fixing the specificity of the CNN to the electrophysiologist adjudicators’ specificity, the CNN identified all SVT classes with higher sensitivity: (1) AVNRT (91.7% vs 65.9%), (2) AVRT (78.4% vs 63.6%), and (3) AT (61.5% vs 50.0%).
A CNN can be trained to differentiate SVT mechanisms from surface 12-lead ECGs with high overall performance, achieving similar performance to experienced electrophysiologists at fixed specificities.
Diagnostic Accuracy of Several Electrocardiographic Criteria for the Prediction of Atrioventricular Nodal Reentrant Tachycardia
2016, Archives of Medical Research
Citation Excerpt :
However, variation in the diagnostic accuracy among those classical ECG findings is not well known. Electrophysiological (EP) testing has been used to assess the inducibility and mechanism of SVT and to guide catheter ablation using radiofrequency, which has become the preferred treatment for symptomatic SVT (10,22). Accurate prediction of SVT by upfront ECG may be helpful in planning the ablation, potentially decreasing the duration of the procedure, time of radiation and likelihood of complications.
Atrioventricular nodal reentrant tachycardia (AVNRT) is the most common form of paroxysmal supraventricular tachycardia (SVT) whose diagnosis can be strongly suspected based on the surface eletrocardiogram alone. The purpose of this study is to determine the diagnostic accuracy of several electrocardiographic (ECG) criteria for the prediction of AVNRT.
Between November 2010 and January 2014, a total of 256 patients who underwent electrophysiological testing (EP) with regular, paroxysmal and narrow QRS complex tachycardia were prospectively enrolled. We classified the ECG recordings during tachycardia for the presence of the following criteria: a) classical ECG findings of pseudo S wave in inferior leads and/or pseudo r′ wave in lead V1, b) notch in lead aVL, c) no retrograde P waves visible during tachycardia; d) pseudo r′ wave in lead aVR, e) notch in lead D1, f) any deflection after 100 ms of the QRS complex during tachycardia.
On multivariate analysis, independent predictors of AVNRT diagnosis were female sex (OR 4.17; 95% CI [2.11–8.24]; p <0.001), age >60 years (OR 3.53; 95% CI [1.25–9.96]; p = 0.017) and the classical ECG criteria (OR 7.41; 95% CI [3.62–15.17]; p <0.001).
Female, age >60 years and the classical ECG criteria were the independent predictors of AVNRT diagnosis. Although several of the ECG criteria for AVNRT diagnosis showed acceptable sensitivities and specificities, they do not improve its accuracy.
The classical versus the Cabrera presentation system for resting electrocardiography: Impact on recognition and understanding of clinically important electrocardiographic changes
2015, Journal of Electrocardiology
The classical system for presentation of the 12-lead electrocardiogram (ECG) reflects the electrical activity of the heart as viewed in the transverse plane by 6 leads with a single anatomically ordered sequence, V₁–V₆; but in the frontal plane by 6 leads with dual sequences, I, II, and III, and aVR, aVL, and aVF. However, there is also a single anatomically ordered sequence of leads, called the Cabrera display that presents the six frontal plane leads in their anatomically ordered sequence of: aVL, I, − aVR, II, aVF, and III. Although it has been recognized that the Cabrera system has clinical diagnostic advantages compared to the classical display, it is currently only used in Sweden.
The primary explanation of why the Cabrera system has not been adopted internationally has been that analog ECG recorders had technical limitations. Currently, however, the classical system is most often seen as a historical remnant that prevails because of conservatism within the cardiology community.
Electrocardiographic applications of lead aVR
2006, American Journal of Emergency Medicine
Lead aVR, 1 of 12 electrocardiographic leads, is frequently ignored in clinical medicine. In fact, many clinicians refer to the 12-lead electrocardiogram (ECG) as the 11-lead ECG, noting the commonly held belief that lead aVR rarely offers clinically useful information. In this report, we discuss the findings in lead aVR, which are potentially of value, including ST-segment elevation in the patient with acute coronary syndrome suggestive of left main coronary artery occlusion, PR-segment elevation in the patient with acute pericarditis, prominent R wave in the patient with significant tricyclic antidepressant poisoning, and ST-segment elevation in narrow complex tachycardia suggestive of Wolff-Parkinson-White syndrome.
A new criterion to differentiate atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia: Combined AVR criterion
2018, Journal of Electrocardiology
Citation Excerpt :
In a previous study, ST segment elevation in the aVR was found to indicate AVRT as the tachycardia mechanism [4]. In this study, retrograde P waves in AVRT were thought to cause ST segment elevation [4]. Haghjoo M. et al. [3] showed that a retrograde P wave may cause a pseudo r′ deflection in aVR due to a short VA interval in patients with AVNRT.
A combined aVR criterion is described as the presence of a pseudo r′ wave in aVR during tachycardia in patients without r′ wave in aVR in sinus rhythm and/or a ≥50% increase in r′ wave amplitude compared to sinus rhythm in patients with r′ wave in the basal aVR lead. We aimed to investigate the use of combined aVR criterion in differential diagnosis of atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT).
In this prospective study, 480 patients with inducible narrow QRS supraventricular tachycardia (SVT) were included. Twelve-lead electrocardiogram (ECG) was conducted during tachycardia and sinus rhythm. The patients were divided into two groups according to the arrhythmia mechanism that determined via EPS, AVNRT, and AVRT. Criteria of narrow QRS complex tachycardia were compared between the two groups.
AVNRT was present in 370 (77%) patients and AVRT in 110 (23%) patients. Combined aVR criterion was found to be more frequent in patients with AVNRT (84.1% and 9.1%, p < 0.001). In logistic regression analysis, combined aVR criterion and classical ECG criterion were found to be the most important predictors of AVNRT (p < 0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of the combined aVR criterion for AVNRT were 84.1%, 90.9%, 96.9%, and 62.9%, respectively.
In the differential diagnosis of patients with SVT, the combined aVR criterion identifies the presence of AVNRT with an independent and acceptable diagnostic value. In addition to classical ECG criteria for AVNRT, it is necessary to evaluate the combined aVR criterion in daily practice.
Heart rate is a predictor of success in the treatment of adults with symptomatic paroxysmal supraventricular tachycardia
2004, European Heart Journal

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Arrhythmias and conduction disturbancesUsefulness of ST-segment elevation in lead aVR during tachycardia for determining the mechanism of narrow QRS complex tachycardia

Abstract

Section snippets

Electrocardiographic analysis

Results

Discussion

Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography

J Am Coll Cardiol

Simple electrocardiographic criteria for identifying the site of origin of focal right atrial tachycardia

Pacing Clin Electrophysiol

Value of analysis of ST segment changes during tachycardia in determining type of narrow QRS complex tachycardia

J Am Coll Cardiol

Dobutamine-induced ST-segment elevation in patients with acute myocardial infarction and the role of myocardial ischemia, viability, and ventricular dyssynergy

Am J Cardiol

Significance of dobutamine-induced ST-segment elevation and T-wave pseudo-normalization in patients with Q-wave myocardial infarctionsimultaneous evaluation by dobutamine stress echocardiography and thallium-201 SPECT

Am J Cardiol

Initiation of two distinct forms of atrioventricular nodal reentrant tachycardia during programmed ventricular stimulation in man

Am J Cardiol

Prospective evaluation of the length of the lower common pathway in the differential diagnosis of various forms of AV nodal reentrant tachycardia

Pacing Clin Electrophysiol

Atrioventricular nodal reentry with an anterograde slow pathway and retrograde slow pathway (abstr)

J Am Coll Cardiol

The standard 11-lead ECG. Neglect of lead aVR in the classical limb lead display

J Electrocardiol

Arrhythmias and conduction disturbances
Usefulness of ST-segment elevation in lead aVR during tachycardia for determining the mechanism of narrow QRS complex tachycardia