Differential Diagnostics of Wide QRS Complex Arrhythmias with Left Bundle Branch Block Morphology Using Slow Conduction Index

Abstract

Differential diagnosis of wide QRS complex arrhythmias is one of the most challenging tasks in routine practice arrhythmology. The analysis of the wide QRS complex morphology has been introduced due to the complex problem of detecting atrial waves on ECG. A slow conduction index based on the ratio of the initial and terminal QRS amplitudes is one of the solutions to evaluate conduction velocity based on the surface ECG due to a significant variability of QRS morphology and real complexity of its detailed assessment. However, one of the significant limitations of this algorithm is a need to search for the RS wide complex type and randomly select an ECG lead with this morphology which can finally create a contradictory result.

AIM: To evaluate a possibility of using the slow conduction index for differential diagnosis of wide QRS complex arrhythmias with left bundle branch (LBBB) morphology in any of 12-leads ECG followed by evaluation of the obtained diagnostic accuracy values.

MATERIALS AND METHODS: The study included 280 single premature wide QRS complexes with LBBB morphology recorded during holter ECG monitoring in randomly selected 28 patients. Atrial extrasystoles were recorded in 14 patients and ventricular extrasystoles were captured during sinus rhythm in other 14 patients. A ROC analysis was used for the qualitative and quantitative assessment of a slow conduction index diagnostic values based on sensitivity (Sn), specificity (Sp) and accuracy (Acc).

RESULTS: The highest values of Sn and Sp were obtained for a slow conduction index in the leads aVL, V2, aVF, V5 and III, and the lowest — for the leads I, V3 and V6 based on the calculated area (AUC) under the ROC curves (p < 0.001 for all leads).

CONCLUSION: The study presented the fundamental possibility of using a slow conduction index in any of 12-lead ECG for the differential diagnosis of wide QRS complex arrhythmias with LBBB morphology.

Keywords

differential diagnosis / wide QRS complex / left bundle branch block

References

[1] Abedin Z. Differential diagnosis of wide QRS tachycardia: A review. J Arrhythm. 2021;37(5):1162-1172. DOI:10.1002/joa3.12599.

[2] Abedin Z. Differential diagnosis of wide QRS tachycardia: A review // Journal of arrhythmia. 2021. 37. № 5. С. 1162–1172. DOI: 10.1002/joa3.12599.

[3] Медведев ММ. Дифференциальная диагностика тахикардий с широкими комплексами QRS: от «классических» признаков к первым алгоритмам. Вестник аритмологии. 2019;26(3):48-56. DOI:10.35336/VA-2019-3-48-56.

[4] Медведев М.М. Дифференциальная диагностика тахикардий с широкими комплексами QRS: от «классических» признаков к первым алгоритмам // Вестник аритмологии. 2019. 26. № 3. С. 48–56. DOI: 10.35336/VA-2019-3-48-56.

[5] Alzand BSN, Crijns HJGM. Diagnostic criteria of broad QRS complex tachycardia: decades of evolution. Europace. 2011;13(4): 465-472. DOI:10.1093/europace/euq430.

[6] Alzand B.S.N., Crijns H.J.G.M. Diagnostic criteria of broad QRS complex tachycardia: decades of evolution // Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2011. 13. № 4. С. 465–472. DOI: 10.1093/europace/euq430.

[7] Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83(5):1649-1659. DOI:10.1161/01.cir.83.5.1649.

[8] Brugada P., Brugada J., Mont L., Smeets J., Andries E. W. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex // Circulation. 1991. 83. № 5. С. 1649–1659. DOI: 10.1161/01.cir.83.5.1649.

[9] Kim M, Kwon CH, Lee JH, et al. Right bundle branch block-type wide QRS complex tachycardia with a reversed R/S complex in lead V6: Development and validation of electrocardiographic differentiation criteria. Heart Rhythm. 2021;18(2):181-188. DOI:10.1016/j.hrthm.2020.08.023.

[10] Kim M., Kwon C.H., Lee J.H., Hwang K.W., Choi H.O., Kim Y.-G., Lee K.-N., Ahn J., Park H.-S., Nam G.-B. Right bundle branch block-type wide QRS complex tachycardia with a reversed R/S complex in lead V6: Development and validation of electrocardiographic differentiation criteria // Heart rhythm. 2021. 18. № 2. С. 181–188. DOI: 10.1016/j.hrthm.2020.08.023.

[11] Chen Q, Xu J, Gianni C, et al. Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm. Heart Rhythm. 2020;17(3):431-438. DOI:10.1016/j.hrthm.2019.09.021.

[12] Chen Q., Xu J., Gianni C., Trivedi C., Della Rocca D.G., Bassiouny M., Canpolat U., Tapia A.C., Burkhardt J. D., Sanchez J.E., Hranitzky P., Gallinghouse G.J., Al-Ahmad A., Horton R., Di Biase L., Mohanty S., Natale A. Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm // Heart rhythm. 2020. 17. № 3. С. 431–438. DOI: 10.1016/j.hrthm.2019.09.021.

[13] Drew BJ, Scheinman MM. ECG Criteria to Distinguish Between Aberrantly Conducted Supraventricular Tachycardia and Ventricular Tachycardia:Practical Aspects for the Immediate Care Setting. Pacing Clin Electro. 1995;18(12):2194-2208. DOI:10.1111/j.1540-8159.1995.tb04647.x.

[14] Drew B.J., Scheinman M.M. ECG Criteria to Distinguish Between Aberrantly Conducted Supraventricular Tachycardia and Ventricular Tachycardia:Practical Aspects for the Immediate Care Setting // Pacing and Clinical Electrophysiology. 1995. 18. № 12. С. 2194–2208. DOI: 10.1111/j.1540-8159.1995.tb04647.x.

[15] May AM, Brenes-Salazar JA, DeSimone CV, et al. Electrocardiogram algorithms used to differentiate wide complex tachycardias demonstrate diagnostic limitations when applied by non-cardiologists. J Electrocardiol. 2018;51(6):1103-1109. DOI:10.1016/j.jelectrocard.2018.09.015.

[16] May A.M., Brenes-Salazar J.A., DeSimone C.V., Vaidya V.R., Ternus B.W., Hodge D. O., Lin G., Mulpuru S. K., Deshmukh A.J., Noseworthy P.A., Brady P.A. Electrocardiogram algorithms used to differentiate wide complex tachycardias demonstrate diagnostic limitations when applied by non-cardiologists // Journal of electrocardiology. 2018. 51. № 6. С. 1103–1109. DOI: 10.1016/j.jelectrocard.2018.09.015.

[17] Медведев ММ, Парижский АБ. Почему «не работают» электрокардиографические алгоритмы дифференциальной диагностики тахикардий с широкими комплексами QRS. Вестник аритмологии. 2020;27(2):54-66. DOI:10.35336/VA-2020-2-54-66.

[18] Медведев М. М., Парижский А. Б. Почему «не работают» электрокардиографические алгоритмы дифференциальной диагностики тахикардий с широкими комплексами QRS // Вестник аритмологии. 2020. 27. № 2. С. 54–66. DOI: 10.35336/VA-2020-2-54-66.

[19] Vereckei A, Duray G, Szenasi G, Altemose GT, Miller JM. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J. 2007;28(5):589-600. DOI:10.1093/eurheartj/ehl473.

[20] Vereckei A., Duray G., Szenasi G., Altemose G.T., Miller J.M. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia // European heart journal. 2007. 28. № 5. С. 589–600. DOI: 10.1093/eurheartj/ehl473.

[21] Shapiro SS, Wilk MB. An Analysis of Variance Test for Normality (Complete Samples). Biometrika. 1965;52(3/4):591. DOI:10.2307/2333709.

[22] Shapiro S.S., Wilk M.B. An Analysis of Variance Test for Normality (Complete Samples) // Biometrika. 1965. 52. 3/4. С. 591. DOI: 10.2307/2333709.

[23] Royston P. A Toolkit for Testing for Non-Normality in Complete and Censored Samples. Journal of the Royal Statistical Society. Series D (The Statistician). 1993;42(1):37-43. http://www.jstor.org/stable/2348109. Accessed December 2, 2022.

[24] Royston P.A Toolkit for Testing for Non-Normality in Complete and Censored Samples // Journal of the Royal Statistical Society. Series D (The Statistician). 1993. 42. № 1. С. 37–43.

[25] Sheskin D. Handbook of parametric and nonparametric statistical procedures. 5th ed. Boca Raton: CRC Press; 2011.

[26] Sheskin D. Handbook of parametric and nonparametric statistical procedures. 5-e изд. Boca Raton: CRC Press, 2011. xxxix,1886.

[27] Metz CE. Basic principles of ROC analysis. Semin Nucl Med. 1978;8(4):283-298. DOI:10.1016/s0001-2998(78)80014-2.

[28] Metz C.E. Basic principles of ROC analysis // Seminars in nuclear medicine. 1978. 8. № 4. С. 283–298. DOI: 10.1016/s0001-2998(78)80014-2.

[29] Zweig MH, Campbell G. Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine. Clin Chem. 1993;39(4):561-577.

[30] Zweig M. H., Campbell G. Receiver-operating characteristic (ROC) plots: a fundamental evaluation tool in clinical medicine // Clinical chemistry. 1993. 39. № 4. С. 561–577.

[31] Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29-36. DOI:10.1148/radiology.143.1.7063747.

[32] Hanley J.A., McNeil B.J. The meaning and use of the area under a receiver operating characteristic (ROC) curve // Radiology. 1982. 143. № 1. С. 29–36. DOI: 10.1148/radiology.143.1.7063747.

[33] Hanley JA, Hajian-Tilaki KO. Sampling variability of nonparametric estimates of the areas under receiver operating characteristic curves: an update. Academic Radiology. 1997;4(1):49-58. DOI:10.1016/s1076-6332(97)80161-4.

[34] Hanley J.A., Hajian-Tilaki K.O. Sampling variability of nonparametric estimates of the areas under receiver operating characteristic curves: an update // Academic Radiology. 1997. 4. № 1. С. 49–58. DOI: 10.1016/s1076-6332(97)80161-4.

[35] Hilgers RA. Distribution-free confidence bounds for ROC curves. Methods Inf Med. 1991;30(2):96-101.

[36] Hilgers R.A. Distribution-free confidence bounds for ROC curves // Methods of information in medicine. 1991. 30. № 2. С. 96–101.

[37] Clopper CJ, Person ES. The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika. 1934;26(4): 404-413. DOI:10.1093/biomet/26.4.404.

[38] Clopper C.J., Person E. S. The use of confidence or fiducial limits illustrated in the case of the binomial // Biometrika. 1934. 26. № 4. С. 404–413. DOI: 10.1093/biomet/26.4.404.

[39] 20. Krishnamoorthy K, Peng J. Some Properties of the Exact and Score Methods for Binomial Proportion and Sample Size Calculation. Communications in Statistics – Simulation and Computation. 2007;36(6):1171-1186. DOI:10.1080/03610910701569218.

[40] Krishnamoorthy K., Peng J. Some Properties of the Exact and Score Methods for Binomial Proportion and Sample Size Calculation // Communications in Statistics - Simulation and Computation. 2007. 36. № 6. С. 1171–1186. DOI: 10.1080/03610910701569218.

[41] Dunn OJ. Multiple Comparisons among Means. Journal of the American Statistical Association. 1961;56(293):52-64. DOI:10.1080/01621459.1961.10482090.

[42] Dunn O.J. Multiple Comparisons among Means // Journal of the American Statistical Association. 1961. 56. № 293. С. 52–64. DOI: 10.1080/01621459.1961.10482090.

[43] Wellens HJ, Brugada P, Wellens HJ, Brugada P. Diagnosis of ventricular tachycardia from the 12-lead electrocardiogram // Diagnosis of Ventricular Tachycardia from the 12-Lead Electrocardiogram. Cardiology clinics. 1987;5(3):511-525. DOI:10.1016/s0733-8651(18)30538-1.

[44] Wellens H.J., Brugada P., Wellens H.J., Brugada P. Diagnosis of ventricular tachycardia from the 12-lead electrocardiogram // Diagnosis of Ventricular Tachycardia from the 12-Lead Electrocardiogram // Cardiology clinics. 1987. 5. № 3. С. 511–525. DOI: 10.1016/s0733-8651(18)30538-1.

[45] Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias. Am J Cardiol. 1988;61(15):1279-1283. DOI:10.1016/0002-9149(88)91169-1.

[46] Kindwall K.E., Brown J., Josephson M.E. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block morphology tachycardias // The American journal of cardiology. 1988. 61. № 15. С. 1279–1283. DOI: 10.1016/0002-9149(88)91169-1.

[47] Griffith JM, Belder AM de, Linker JN, et al. Multivariate analysis to simplify the differential diagnosis of broad complex tachycardia. British Heart Journal. 1991;66(2):166-174. DOI:10.1136/hrt.66.2.166.

[48] Griffith J.M., Belder A.M. de, Linker J.N., Ward D.E., Camm A. John, Griffith M.J., Belder M.A. de, Linker N.J., WARD D.E., Camm A.J. Multivariate analysis to simplify the differential diagnosis of broad complex tachycardia // British Heart Journal. 1991. 66. № 2. С. 166–174. DOI: 10.1136/hrt.66.2.166.

[49] Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. DOI:10.1016/j.hrthm.2007.09.020.

[50] Vereckei A., Duray G., Szénási G., Altemose G.T., Miller J.M. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia // Heart rhythm. 2008. 5. № 1. С. 89–98. DOI: 10.1016/j.hrthm.2007.09.020.

[51] Griffith MJ, Belder MA de, Linker NJ, Ward DE, Camm AJ. Difficulties in the use of electrocardiographic criteria for the differential diagnosis of left bundle branch block pattern tachycardia in patients with a structurally normal heart. Eur Heart J. 1992;13(4):478-483. DOI:10.1093/oxfordjournals.eurheartj.a060200.

[52] Griffith M.J., Belder M.A. de, Linker N.J., Ward D.E., Camm A.J. Difficulties in the use of electrocardiographic criteria for the differential diagnosis of left bundle branch block pattern tachycardia in patients with a structurally normal heart // European heart journal. 1992. 13. № 4. С. 478–483. DOI: 10.1093/oxfordjournals.eurheartj.a060200.

Funding

Ministry of Health of the Russian FederationМинистерство Здравоохранения Российской Федерации(AAAA-A20)

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