Criteria, old and new, for differentiating between ectopic ventricular beats and aberrant ventricular conduction in the presence of atrial fibrillation

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Summary

When anomalous beats occur during atrial fibrillation, one must always consider the important differentiation between an ectopic ventricular mechanism and aberrant ventricular conduction. Anomalous beats are common and were present in 58.6 per cent of 544 consecutive examples of atrial fibrillation.

We stress the inadequacies of existing criteria for differentiating between ventricular ectopy and aberration in the presence of atrial fibrillation—fixed versus variable coupling, RBBB pattern, presence or absence of postanomalous pause, preceding long cycle. We have presented several additional criteria including the QRS morphology (triphasic RSR' versus monophasic or diphasic pattern in V1); initial vector (of anomalous beat compared with that of normally conducted beats); long-short cycle-sequence comparisons; pattern of previous or subsequent anomalous beats during sinus rhythm; and undue prematurity.

Ventricular extrasystolic bigeminy and other nonextrasystolic ectopic ventricular mechanisms (escape, parasystole) can usually be recognized with reasonable certainty.

The relative value of each criterion is tentatively assessed and given an approximate specificity rating. Attention to the QRS contour and comparison of the initial deflection of the anomalous beat with that of flanking conducted beats seem to us to be the most fruitful criteria yet proposed. Even after applying all available criteria, many anomalous beats during atrial fibrillation defy differentiation.

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From the Rogers Heart Foundation, St. Petersburg, Florida.

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