From the Guidelines
Management of ventricular tachycardia (VT) should prioritize the patient's hemodynamic stability, with direct current cardioversion recommended for patients presenting with sustained VT and haemodynamic instability, as stated in the 2015 ESC guidelines 1. The approach to managing VT depends on the patient's symptoms and tolerance of the arrhythmia.
- For patients with monomorphic VT and haemodynamic instability, direct cardioversion is the recommended treatment, with immediate sedation given before cardioversion if the patient is hypotensive but conscious 1.
- For patients with wide complex tachycardia who are haemodynamically stable, electrical cardioversion should be the first-line approach 1.
- Intravenous procainamide or flecainide may be considered for patients who do not present with severe heart failure or acute myocardial infarction, while intravenous amiodarone may be considered in patients with heart failure or suspected ischemia 1. Key considerations in managing VT include:
- Identifying and addressing underlying causes such as ischemia, electrolyte abnormalities, or medication toxicity
- Using antiarrhythmic medications such as amiodarone, lidocaine, or procainamide to prevent further recurrences
- Considering implantable cardioverter-defibrillator (ICD) therapy for patients with structural heart disease or recurrent episodes 1
- Catheter ablation may be considered for recurrent VT despite medical therapy 1. The most recent and highest quality study, the 2015 ESC guidelines 1, provides the basis for these recommendations, prioritizing the patient's hemodynamic stability and symptoms in the management of VT.
From the FDA Drug Label
Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. The recommended starting dose of amiodarone is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone (mixed in 100 mL of D5W and infused over 10 minutes to minimize the potential for hypotension)
The management of VT with amiodarone involves:
- Initiating treatment with a starting dose of about 1000 mg over the first 24 hours of therapy
- Using a maintenance infusion rate of 0.5 mg/min (720 mg per 24 hours) after the first 24 hours
- Administering 150 mg supplemental infusions of amiodarone in the event of breakthrough episodes of VF or hemodynamically unstable VT 2 2
From the Research
Management of Ventricular Tachycardia (VT)
- VT is a life-threatening condition that requires immediate attention and treatment 3, 4, 5, 6, 7
- The management of VT depends on the patient's hemodynamic status and the underlying cause of the arrhythmia 3, 4
Classification of VT
- VT can be classified into two main types: monomorphic and polymorphic 3, 4
- Monomorphic VT is characterized by a uniform QRS complex morphology, while polymorphic VT has a variable QRS complex morphology 3, 4
Treatment of VT
- Direct current cardioversion is the most effective treatment for VT, especially in patients who are hemodynamically unstable 3, 4
- Antiarrhythmic drugs such as procainamide, amiodarone, and lidocaine can be used to treat VT, but their effectiveness varies depending on the patient's condition and the underlying cause of the arrhythmia 3, 5, 7
- Procainamide is considered the most effective antiarrhythmic drug for treating monomorphic VT, but its use is limited by its potential side effects 3
Management of Refractory VT
- Refractory VT requires aggressive treatment, including the use of antiarrhythmic drugs and electrical cardioversion 4, 5
- The choice of antiarrhythmic drug depends on the patient's condition and the underlying cause of the arrhythmia, as well as the availability and cost of the drug 5