An asymptomatic man in his 50s with heart rate in the 160s - what is the diagnosis? How will you manage this?

 Written by Pendell MeyersA man in his late 50s with history of CAD with CABG, COPD, smoking, cirrhosis, and other comorbidities presented for an outpatient scheduled stress test which had been ordered for some exertional shortness of breath, palpitations, and presyncopal episodes over the past few months. When he presented to the office for the stress test, his screening vitals before any test or intervention were remarkable only for a heart rate of 160 bpm. He denied any symptoms whatsoever.A 12-lead ECG was performed in the office:What do you think?The ECG shows a wide complex regular monomorphic tachycardia. I measure approximately 60-80 msec from QRS onset to R wave peak in several leads, with total QRS duration approximately 170-180 msec (computer QRS duration 182 msec).Thus, the rhythm differential is VT vs. ST/SVT/Flutter with aberrancy. Even without further ECG expertise, VT is overwhelmingly more likely given age, cardiac history, comorbidities, sheer QRS duration, and simply the fact that VT is already more common than SVT with aberrancy even before historical information is considered.The QRS morphology could be considered for RBBB and LAFB morphology, which could occur in SVT/ST/Flutter with RBBB/LAFB, idiopathic VT of the posterior fascicle, etc. I would assume it is VT until proven otherwise. Adenosine is perfectly safe and reasonable, but this is unlikely to be SVT, and thus I would not bother with it. If posterior fascicle idiopathic VT were being c...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs