What is the management of ventricular (V) tachycardia?

Management of Ventricular Tachycardia

Direct current cardioversion is recommended as first-line treatment for patients presenting with sustained ventricular tachycardia (VT) and hemodynamic instability. 1

Initial Assessment and Classification

The management of VT depends primarily on two key factors:

1. Hemodynamic stability - Is the patient stable or unstable?
2. VT morphology - Is the VT monomorphic or polymorphic?

Hemodynamically Unstable VT

For patients with hemodynamic instability (hypotension, altered mental status, signs of shock, or severe heart failure):

• Immediate synchronized cardioversion at maximum output 1
• Sedate patient first if conscious but unstable 1
• Place defibrillator patches at least 8cm from ICD generator if present 1

Hemodynamically Stable VT

Monomorphic VT:

1. First-line pharmacological treatment:

   • IV procainamide: 10 mg/kg at 50-100 mg/min over 10-20 minutes 1, 2
   • Monitor blood pressure and ECG during administration

2. Alternative medications:

   • IV amiodarone: 150 mg over 10 minutes (for patients with heart failure or suspected ischemia) 1, 3
   • Can repeat as needed to maximum dose of 2.2g/24 hours 1
   • IV sotalol: 1.5 mg/kg over 5 minutes (avoid in patients with prolonged QT) 1
   • IV lidocaine: 1-1.5 mg/kg IV bolus, followed by maintenance infusion 1-4 mg/min (only for VT associated with acute myocardial ischemia) 1

3. If medications fail:

   • Synchronized cardioversion (after appropriate sedation) 1
   • Transvenous catheter pace termination for refractory or recurrent VT 1

Polymorphic VT:

1. First-line treatment:

   • Direct current cardioversion with appropriate sedation 1

2. Pharmacological management:

   • IV beta blockers: First choice, especially if ischemia is suspected 1
   • IV amiodarone: 150 mg over 10 minutes (in absence of long QT syndrome) 1
   • IV lidocaine: May be considered if associated with acute myocardial ischemia 1

3. Additional measures:

   • Urgent angiography with view to revascularization if myocardial ischemia cannot be excluded 1

Special Considerations

Incessant VT or Electrical Storm

• Urgent catheter ablation is recommended for patients with scar-related heart disease presenting with incessant VT or electrical storm 1

Recurrent ICD Shocks

• Catheter ablation is recommended for patients with ischemic heart disease and recurrent ICD shocks due to sustained VT 1

LV Fascicular VT

• IV verapamil or beta-blockers for patients presenting with LV fascicular VT (RBBB morphology and left axis deviation) 1

Common Pitfalls

1. Misdiagnosis of wide-complex tachycardia: Always presume wide-QRS tachycardia to be VT if diagnosis is unclear 1

2. Inappropriate medication use: Calcium channel blockers such as verapamil and diltiazem should not be used to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction 1

3. Delayed cardioversion: Do not delay cardioversion in unstable patients while attempting medical therapy

4. Inadequate monitoring: Close monitoring of blood pressure and cardiovascular status is essential during administration of antiarrhythmic medications, particularly in patients with heart failure 1

5. Improper amiodarone administration: Infusing amiodarone too rapidly or at concentrations >3 mg/mL can cause serious adverse effects including hepatocellular necrosis and acute renal failure 3

Long-term Management

After acute stabilization:

• Consider catheter ablation after first episode of sustained VT in patients with ischemic heart disease and an ICD 1
• Evaluate for underlying structural heart disease with imaging (preferably cardiac MRI) 1
• Consider ICD implantation for prevention of sudden cardiac death in appropriate patients