Slurred R Ascent in V1: Exception to the Rule
Report:
Ventricular tachycardia 168/min
Comment:
The contour of V1 suggests a rabbit in profile, with overlapping ears – not very helpful. If one, more properly, imagines looking at the rabbit from behind, there is a suggestion of larger right ear – non-contributory in terms of VT diagnosis. The ascent of the R wave is slurred, with sharp descent – definitely against the diagnosis of VT109. This patient had previous RBBB with LAHB (below, Fig 119a), somewhat similar (in axes, at least) to the current rhythm. The rhythm could have changed from AF to flutter, the only atrial tachyarrhythmia AF tends to transform itself into.
Even so, the diagnosis of VT can be made with confidence: the QRS is quite broad (about 0.18”) and bizarre, with Northwest axis in “no-man’s-land” and also rS in V6. It is most unlikely to be a more bizarre form of the preceding RBBB/LAHB. Finally, there’s the drugs: adenosine failed where xylocaine succeeded. This was a VT.
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