Monomorphic Ventricular Tachycardia: RV1 & QSV4-6
Report:
Ventricular tachycardia 214/min
Comment:
The monophasic R in V1 and QS in the left ventricular leads is practically diagnostic of VT. Absence of R waves in V4-6 also precludes an antidromic pre-excited tachycardia99.
The patient ascribed the arrhythmia to stumbling and falling on the ground, but more likely it was the other way around: the rapid VT fell him. He had rather massive concentric LVH on echocardiogram the following day. This masked – or balanced - his anterior infarction (214a), confirmed by CPK and troponin rise since admission. The Q waves in the ECG have many contributors: LVH itself, LAHB and anterior infarction. The MI became obvious later, as it evolved (Fig 214b).
The ECG in sinus rhythm demonstrates the relative insensitivity of the ECG in detecting LVH:
Sokolow + Lyon (Am Heart J, 1949;37:161) S V1+ R V5 orV6> 35 mm - negative for LVH
Cornell criteria (Circulation, 1987;3: 565-72) SV3 + R aVL > 28 mm in men SV3 + R aVL > 20 mm in women - negative for LVH
Framingham criteria (Circulation,1990; 81:815-820) R aVL > 11mm, R V4-6 > 25mm S V1-3 > 25 mm, S V1 orV2 + R V5 orV6 > 35 m, RI + S III >25 mm - negative for LVH.
But, Romhilt + Estes (Am Heart J, 1986:75:752-58) point score system: LAA (3 points), LAD (2), ST segment (3), QRS duration (l) & intrinsicoid deflection (l) bring it to twice the 5 points required for "definite LVH". Their system may be too sensitive!
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