Bidirectional VT Differential Diagnosis

Differential Diagnosis of Bidirectional Ventricular Tachycardia VT, BiVT ECG

✔Bidirectional VT

The tachycardia with an identity crisis.

What you'll see:

Beat-to-beat alternation in QRS axis (often ~180)

RBBB-like morphology, most visible in lead Il or aVF

Regular rhythm, but clearly not your standard VT

Why it most likely happens:

Triggered activity (delayed afterdepolarizations)

Classically: two competing ventricular foci or alternating fascicular exits

Top causes:

Digoxin toxicity (check that level!)

CPVT (stress-induced VT in the young)

Andersen-Tawil syndrome

Rare: aconite poisoning, myocarditis

Key point:

BiVT is rare - but when you see it, it narrows the differential dramatically.

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