Rate-related changes in QRS morphology in patients with fixed bundle branch block: implications for differential diagnosis of wide QRS complex tachycardia

Abstract

Aims: To analyse QRS morphology in response to rapid atrial pacing (RAP) and supraventricular tachycardia (SVT) in patients with pre-existing bundle branch block (BBB).

Methods and results: We prospectively studied 59 patients in sinus rhythm (SR), with QRS > or = 120 ms, and no pre-excitation. Trains of RAP were introduced at increasing rates until atrioventricular block. QRS during SR and last QRS complex of each RAP train were compared on the 12-leads. Previously described criteria for minor and major configuration differences were used to identify QRS changes. During RAP minor QRS changes were seen in 22 (37%) and major changes in 23 (39%) subjects. One patient showed major axis shifts and no one showed a change to the contralateral BBB pattern. QRS changes were significantly and independently related to RAP rate and type of BBB (more frequent if right-BBB). Of 14 subjects (24%) with SVT, 13 displayed the same QRS changes during RAP.

Conclusion: In patients with organic BBB, important changes in QRS morphology, except for a change in the contralateral BBB, can appear during RAP and SVT. Thus, in these patients, a change in QRS morphology during tachycardia does not necessarily imply that it is ventricular tachycardia.