What is the management of sudden ventricular tachycardia (VT)?

From the Guidelines

Management of sudden ventricular tachycardia requires immediate assessment of hemodynamic stability, and for unstable patients, immediate synchronized cardioversion is indicated, as recommended by the 2015 ESC guidelines 1. The first step in management is to determine if the patient is stable or unstable, and this assessment guides the choice of treatment.

• For unstable patients with hypotension, altered mental status, chest pain, or heart failure, immediate synchronized cardioversion at 100-200 joules is indicated.
• For stable patients, intravenous antiarrhythmic medications are the first-line treatment, with options including:
  • Amiodarone 150 mg IV over 10 minutes, followed by an infusion of 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours, as recommended by the 2015 ESC guidelines 1 and the 1996 ACC/AHA guidelines 1.
  • Lidocaine (1-1.5 mg/kg IV bolus, followed by 0.5-0.75 mg/kg every 5-10 minutes if needed, maximum 3 mg/kg) or procainamide (20-50 mg/min until arrhythmia suppression, hypotension, QRS widening >50%, or maximum dose of 17 mg/kg), as recommended by the 1996 ACC/AHA guidelines 1 and the 2006 ACC/AHA/ESC guidelines 1.
  • Magnesium sulfate (2 g IV over 15 minutes) can be beneficial for torsades de pointes, as recommended by the 2010 American Heart Association guidelines 1. After acute management, patients require evaluation for underlying causes, including ischemia, electrolyte abnormalities, or structural heart disease, and long-term management may include oral antiarrhythmics, catheter ablation, or implantable cardioverter-defibrillator placement, depending on the underlying etiology, as recommended by the 2015 ESC guidelines 1. Key considerations in the management of ventricular tachycardia include:
• Prompt recognition and treatment to prevent deterioration into ventricular fibrillation and sudden cardiac death, as emphasized by the 2010 American Heart Association guidelines 1.
• Individualized treatment based on the patient's hemodynamic stability and underlying conditions, as recommended by the 2015 ESC guidelines 1 and the 2006 ACC/AHA/ESC guidelines 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. 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 sudden ventricular tachycardia involves the use of amiodarone (IV). The recommended dose is 1000 mg over the first 24 hours of therapy. If breakthrough episodes of VT occur, 150 mg supplemental infusions of amiodarone can be used. Key points to consider are:

• Initial dose: 1000 mg over 24 hours
• Supplemental dose: 150 mg for breakthrough episodes
• Administration: through a central venous catheter, with an in-line filter, and using a volumetric infusion pump 2, 2 The acute effectiveness of intravenous amiodarone in suppressing recurrent VF or hemodynamically unstable VT is supported by two randomized, parallel, dose-response studies 2

From the Research

Management of Sudden Ventricular Tachycardia

• The management of sudden ventricular tachycardia involves the use of antiarrhythmic drugs and other interventions to terminate the arrhythmia and prevent recurrence 3, 4, 5, 6, 7.
• Amiodarone is a commonly used antiarrhythmic drug for the treatment of ventricular tachycardia, and has been shown to be effective in terminating the arrhythmia and preventing recurrence 3, 5, 7.
• Other antiarrhythmic drugs, such as procainamide, ajmaline, and sotalol, have also been used to treat ventricular tachycardia, but their efficacy and safety compared to amiodarone are not well established 4, 7.
• Catheter ablation is also a treatment option for ventricular tachycardia, and has been shown to be effective in reducing the recurrence of the arrhythmia and the need for implantable cardioverter-defibrillator (ICD) shocks 7.

Treatment Options

• Amiodarone: effective in terminating and preventing ventricular tachycardia, but requires careful patient surveillance due to potential adverse effects 3, 5, 7.
• Procainamide: may be effective in treating ventricular tachycardia, but its efficacy and safety compared to amiodarone are not well established 4, 5.
• Ajmaline: may be effective in treating ventricular tachycardia, but its efficacy and safety compared to amiodarone are not well established 4.
• Sotalol: may increase the risk of ventricular tachycardia recurrence and ICD shocks compared to amiodarone 7.
• Catheter ablation: effective in reducing the recurrence of ventricular tachycardia and the need for ICD shocks, but requires careful consideration of patient characteristics and potential complications 7.

Diagnosis and Management Considerations

• Accurate diagnosis of ventricular tachycardia is important to allow prompt referral to specialist services for ongoing management 6.
• Distinguishing between ventricular tachycardia and supraventricular arrhythmias on electrocardiogram (ECG) can be difficult, but is crucial for guiding treatment decisions 6.
• The management of ventricular tachycardia requires consideration of the underlying substrate and the patient's clinical characteristics, as well as the potential risks and benefits of different treatment options 6, 7.