Vereckei criteria as a diagnostic tool amongst emergency medicine residents to distinguish between ventricular tachycardia and supra-ventricular tachycardia with aberrancy

Abstract

Background Accurate electrocardiographic (ECG) differentiation of ventricular tachycardia (VT) from supraventricular tachycardia with aberrancy (SVT-A) on ECG is key to therapeutic decision-making in the emergency department (ED) setting. Objective The goal of this study was to test the accuracy and agreement of emergency medicine residents to differentiate VT from SVT-A using the Vereckei criteria. Methods Six emergency medicine residents volunteered to participate in the review of 114 ECGs from 86 patients with a diagnosis of either VT or SVT-A based on an electrophysiology study. The resident reviewers initially read 12-lead ECGs blinded to clinical information, and then one week later reviewed a subset of the same 12-lead ECGs unblinded to clinical information. Results One reviewer was excluded for failing to follow study protocol and one reviewer was excluded for reviewing less than 50 blinded ECGs. The remaining four reviewers each read 114 common ECGs blinded to clinical data and their diagnostic accuracy for VT was 74% (sensitivity 70%, specificity 80%), 75% (sensitivity 76%, specificity 73%), 61% (sensitivity 81%, specificity 25%), and 68% (sensitivity 84%, specificity 40%). The intraclass correlation coefficient (ICC) was 0.31 (95% CI 0.22 – 0.42). Eliminating two of the four reviewers who left a disproportionately high number of ECGs unclassified resulted in an increase in overall mean diagnostic accuracy (70% to 74%) and agreement (0.31 to 0.50) in the two remaining reviewers. Three reviewers read 45 common ECGs unblinded to clinical information and had accuracies for VT 93%, 93% and 78%. Conclusion The new single lead Vereckei criteria, when applied by emergency medicine residents achieved only fair-to-good individual accuracy and moderate agreement. The addition of clinical information resulted in substantial improvement in test characteristics. Further improvements (accuracy and simplification) of algorithms for differentiating VT from SVT-A would be helpful prior to clinical implementation.

Comparison of the “Real-life” Diagnostic Value of Two Recently Published Electrocardiogram Methods for the Differential Diagnosis of Wide QRS Complex Tachycardias

“…However, the potential misclassification of their 23 preexcitation SVTs out of the total 260 WCTs might not have significantly changed the conclusions of Jastrzebski et al . In a recent report, four emergency resident reviewers analyzed WCT ECG tracings using the aVR Vereckei algorithm . When two of the four reviewers who left disproportionately high numbers of ECGs unclassified at the final step of the algorithm were eliminated from the analysis, the two remaining reviewers achieved a somewhat lower but similar overall test accuracy (70 and 74%) to the mean overall test accuracy of our three inexperienced observers (81.3%).…”

“…It seems prudent to consider and treat all sustained, regular WCTs as VT unless the diagnosis of SVT can be definitely established, because it is far better to be wrong with a few cases of SVT treated as VT than the reverse situation, since treating a VT as SVT may result in potentially disastrous consequences (e.g., intravenous [IV] verapamil injection may cause severe hypotension and/or VT acceleration and ventricular fibrillation). When ECG methods for WCT differentiation were applied by physicians, the reported diagnostic accuracy of a particular ECG method is usually lower than that reported by the original authors . Therefore, we sought to compare the diagnostic value of two recently published simple ECG methods, the aVR lead “Vereckei algorithm,” and the lead II R‐wave peak time (RWPT) criterion, for differential diagnosis of WCTs in “real life.”…”

Are Available Electrocardiographic Methods Accurate Enough to Diagnose Ventricular Tachycardia in the Emergency Department?

“…13 Previous studies have described that on the application of the different criteria in daily clinical practice by physicians of different specialties and with different grades of experience, the results differ from those originally published, demonstrating lower diagnostic accuracy, sensitivity, and specificity, as well as a moderate interobserver correlation index. 8,14 One recent study comparing the two new methods of Vereckei and Padua with the three classical methods of Brugada, Bayesian, and Griffith in the differential diagnosis of WCT concluded that diagnostic accuracies were moderate and similar, presenting varying sensitivities and specificities, and diagnostic results were inferior to those of the original studies. 15 With the aim of shedding light on the diagnostic value of these new single-lead ECG methods in daily clinical practice, the Vereckei algorithm (aVR Vereckei algorithm, aVR-alg) and the lead II R wave peak time criterion (RWPT-crit) in the differential diagnosis of WCT and in the diagnostic capacity based on the grade of training and applicability of the same, the November 2013 issue of Academic Emergency Medicine published a study carried out in a consecutive sample of 212 regular and monomorphic WCT from an electrophysiology unit, with final electrophysiologic diagnoses for each case.…”

“…7 Delay in diagnosis or misdiagnosis of VT may cause impairment of the hemodynamic situation or even progression to ventricular fibrillation or cardiac arrest due to inadequate treatment. 7,8 However, on three out of four occasions WCT occurs in hemodynamically stable patients when arriving to the ED, 3 thereby allowing not only differential diagnosis but also pharmacologic treatment as the first option. 2,3 Twelve-lead electrocardiogram (ECG) remains the cornerstone test in the differential diagnosis of WCT within the ED setting.…”

Análise de um novo critério de interpretação no diagnóstico diferencial das taquicardias de complexo QRS largo

“…e relação de voltagem do QRS em derivações específicas, tendo como consequência direta a dificuldade na memorização e na sua aplicabilidade clínica. Um aspecto característico em todos os estudos foi que a alta acurácia, a sensibilidade e a especificidade desses métodos não foram reproduzidas por outros autores47,[57][58][59]62 . em D1 sugerem com maior chance o diagnóstico de TV14,38,50 .Os atuais critérios de interpretação no diagnóstico diferencial das taquicardias de QRS largo podem ser difíceis de memorizar, com chance de erro diagnóstico que não são desprezíveis, especialmente quando os passos sequenciais exigem análises menos visuais e mais numéricas, o que implica maior tempo para o diagnóstico e a decisão…”