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Extra info for ABC of Clinical Electrocardiography
Indirect evidence of independent atrial activity Capture beat Occasionally an atrial impulse may cause ventricular depolarisation via the normal conduction system. The resulting QRS complex occurs earlier than expected and is narrow. Such a beat shows that even at rapid rates the conduction system is able to conduct normally, thus making a diagnosis of supraventricular tachycardia with aberrancy unlikely. Capture beats are uncommon, and though they confirm a diagnosis of ventricular tachycardia, their absence does not exclude the diagnosis.
The normal ST segment usually blends with the T wave smoothly, making it difficult to determine where the ST segment ends and the T wave starts. One of the first and most subtle changes in the ST segment is flattening of the segment, resulting in a more obvious angle between the ST segment and T wave. A C Subtle ST segment change in patient with ischaemic chest pain: when no pain is present (top) and when in pain (bottom) 38 B D ST changes with ischaemia showing normal wave form (A); flattening of ST segment (B), making T wave more obvious; horizontal (planar) ST segment depression (C); and downsloping ST segment depression (D) Substantial ST segment depression in patient with ischaemic chest pain Myocardial ischaemia More obvious changes comprise ST segment depression that is usually planar (horizontal) or downsloping.
Duration and morphology of QRS complex In ventricular tachycardia the sequence of cardiac activation is altered, and the impulse no longer follows the normal intraventricular conduction pathway. 12 s or longer). 16 s. 2 s, particularly if the patient has electrolyte abnormalities or severe myocardial disease or is taking antiarrhythmic drugs, such as flecainide. 14 s. The QRS complex in ventricular tachycardia often has a right or left bundle branch morphology. In general, a tachycardia originating in the left ventricle produces a right bundle branch block pattern, whereas a tachycardia originating in the right ventricle results in a left bundle branch block pattern.