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Jordan Cardiac Society (JCS) Taskforce Congress, October 2025 The Jordanian Task Force Protocol for Manegement of patients with Wide Complex Tachycardia [1]

Jordan Cardiac Society (JCS) Taskforce Congress, October 2025

The Jordanian Task Force Protocol for Manegement of patients with Wide Complex Tachycardia [1]

Laith Saleh, MD and Basil Abu El Haija, MD

Tachycardias are broadly categorized into wide complex and narrow complex tachycardia (based on QRS width, with a cut off of 120 ms)

Initial management

The provider should conduct a brief history and physical examination with an assessment of the symptoms, vital signs, and level of consciousness to determine if they are hemodynamic stable or unstable. During the clinician assessment, other members of the health care team should:

• Administer supplemental oxygen
• Establish intravenous access
• Send blood for appropriate initial studies
• Attach the patient to a continuous cardiac monitor
• Obtain a 12-lead ECG

 

Unstable patients

• Unstable, pulseless: Patients with WCT who are pulseless, or who become pulseless during the course of evaluation and treatment, should be managed according to standard advance cardiac life support (ACLS) resuscitation algorithms
• Unstable, with a pulse: Patients with WCT who are hemodynamically unstable, but still responsive with a discernible blood pressure and pulse should undergo urgent, synchronized when possible, cardioversion (with procedural sedation when feasible).

 

Stable patients with uncertain WCT etiology

For hemodynamically stable patients with WCT which is regular and monomorphic in whom the etiology of the WCT remains uncertain, we suggest the following approach:

 

1. Perform vagal maneuvers (Valsalva, carotid sinus massage, etc): Valsalva maneuvers, cartoid massage, ice water immertion, and assess response:
o Sinus tachycardia will gradually slow during the maneuver and then accelerate upon completion of the maneuver.
o During atrial tachycardia or atrial flutter, the ventricular response will transiently slow (due to increased AV nodal blockade). The arrhythmia itself, which occurs within the atria, is usually unaffected and often better recognized with a slower ventricular rate.
o A paroxysmal SVT (either AVNRT or AVRT) will frequently terminate because of the dependence on the AV node.
o VT is generally unaffected by vagal maneuvers, but the effect on the AV node may expose AV dissociation by altering the sinus rate (or PP intervals). VT termination due to carotid sinus pressure is rare.
2. Administer adenosine

Resuscitation equipment should be immediately available as rarely adenosine will precipitate hemodynamic collapse. The initial dose of adenosine is 6 mg; if this has no effect, 12 mg can be administered.

AVNRT and AVRT will frequently be terminated following adenosine administration. Adenosine will also terminate some uncommon adenosine-sensitive atrial tachycardia and some VTs like idiopathic right ventricular outflow tract (RVOT) VT. However, adenosine has no effect on most tachycardias that are not AV-node dependent.

 

o Adenosine is administered via rapid intravenous push, followed immediately by 10 mL saline flushusing a proximal canula (AC or above)
o If adenosine is administered properly as above and there is no change in the ventricular rate and rhythm, the WCT is likely to be VT.
o In atrial arrhythmia like atrial tachycaredia or atrial flutter, adenosine usually slows the ventricular rate temporarily and the underlying atrial activity is typically easily seen on the ECG.
3. Avoidance of other pharmacologic agents

Intravenous beta blockers, calcium channel blockers, and digoxin are not typically used, due to the potential for hemodynamic deterioration

4. Further treatment is directed by the response to vagal maneuvers and/or adenosine, specifically targeting VT or the relevant SVT. If the WCT persists and the etiology remains uncertain, the treatment should assume that the WCT is VT and treat accordingly.

 

Stable patients with known WCT etiology

In a patient with WCT who is hemodynamically stable, therapy may be targeted to the specific arrhythmia (VT or SVT) when identifiable from the available data.

Ventricular tachycardia

• If electrical cardioversion with appropriate procedural sedation is the chosen approach, intravenous analgesics or sedatives should be cautiously administered if the blood pressure will tolerate their use.
• If pharmacologic cardioversion is the chosen approach, intravenous amiodarone or lidocaine should be used
• Any associated conditions should be treated, including cardiac ischemia, heart failure, electrolyte abnormalities, or drug toxicities.
• For patients with one of the known syndromes of VT in structurally normal hearts, calcium channel blockers or beta blockers may be used, particularly if the patient has been successfully treated in the past with such medications. These drugs can be used either to terminate the arrhythmia, or after cardioversion to suppress recurrences.

 

Supraventricular tachycardia

Once the WCT has been definitively established as SVT, therapy directed at the SVT may be given. In such cases, management is similar to an SVT with a normal QRS duration, and SVT protocols should be implemented with no significant difference.

 

 

1. Adapted from 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020; 41:655; 2017 AHA/ACC/HRS Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

 

 

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