From the Guidelines
Sustained ventricular tachycardia (VTach) should be treated with direct current cardioversion for patients presenting with haemodynamic instability, as recommended by the 2015 ESC guidelines 1.
Treatment Approach
The treatment approach for sustained VTach depends on the patient's hemodynamic stability.
- For patients with haemodynamic instability, direct current cardioversion is the recommended first-line treatment 1.
- In patients who are hypotensive and yet conscious, immediate sedation should be given before undergoing cardioversion 1.
- For patients with wide complex tachycardia who are haemodynamically stable, electrical cardioversion should be the first-line approach 1.
Pharmacological Treatment
Intravenous antiarrhythmic medications can be considered for patients who do not present with severe heart failure or acute myocardial infarction.
- Intravenous procainamide or flecainide may be considered for these patients 1.
- Intravenous amiodarone may be considered in patients with heart failure or suspected ischemia 1.
- Intravenous lidocaine is only moderately effective in treating sustained VTach 1.
Key Considerations
When treating sustained VTach, it is essential to consider the patient's underlying conditions, such as heart failure or coronary artery disease, and to address these conditions as part of the treatment plan.
- The goal of treatment is to suppress abnormal electrical activity in the ventricles and prevent cardiac arrest.
- Implantable cardioverter-defibrillator placement and antiarrhythmic medications may be considered for long-term treatment 1.
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. Procainamide Hydrochloride Injection is indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that, in the judgement of the physician, are life-threatening. Sotalol has been studied in life-threatening and less severe arrhythmias In patients with frequent premature ventricular complexes (VPC), orally administered sotalol was significantly superior to placebo in reducing VPCs, paired VPCs and non-sustained ventricular tachycardia (NSVT); the response was dose-related through 640 mg/day with 80-85% of patients having at least a 75% reduction of VPCs
Treatment Options for Sustained VTach:
- Amiodarone: can be used for acute treatment of sustained VTach until the patient's ventricular arrhythmias are stabilized 2
- Procainamide: is indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that are life-threatening 3
- Sotalol: has been shown to be effective in reducing VPCs, paired VPCs, and non-sustained ventricular tachycardia (NSVT), and can be used for the treatment of life-threatening arrhythmias, including sustained VTach 4
From the Research
Sustained VTach Treatment Options
- The treatment of sustained ventricular tachycardia (VT) can be managed through various methods, including antiarrhythmic drug therapy and electrical cardioversion 5, 6, 7.
- Antiarrhythmic drugs such as procainamide, amiodarone, and lidocaine have been compared in terms of their effectiveness in terminating sustained VT 5, 6, 8.
- Procainamide has been shown to be more effective than lidocaine in terminating sustained monomorphic VT, but its use can be limited by its potential to cause hypotension 5, 8.
- Amiodarone has also been used to treat sustained VT, but its effectiveness compared to procainamide is uncertain 5, 6.
Comparison of Antiarrhythmic Drugs
- A systematic review of the literature found that procainamide, ajmaline, and sotalol were superior to lidocaine in terminating stable, monomorphic VT 6.
- Another study found that procainamide was more effective than lidocaine in terminating sustained monomorphic VT, with a termination rate of 75.7% compared to 35.0% for lidocaine 8.
- The use of antiarrhythmic drugs during cardiopulmonary resuscitation is uncertain, with some studies suggesting that they may improve survival in patients with witnessed arrest, but others finding no clear benefit 9.
Electrical Cardioversion and Other Treatment Options
- Electrical cardioversion is a highly effective method for terminating sustained VT, especially in patients who are hemodynamically unstable 7.
- Anti-tachycardia pacing and defibrillation are also effective methods for terminating sustained VT, especially in patients with an implanted defibrillator 7.
- The management of sustained VT requires a comprehensive approach, including the evaluation and treatment of underlying cardiac pathologies, as well as the prevention of recurrence and treatment of underlying heart disease 7.