What is the treatment for ventricular tachycardia?

Treatment of Ventricular Tachycardia

The treatment of ventricular tachycardia (VT) requires immediate assessment of hemodynamic stability, with synchronized cardioversion as first-line therapy for unstable VT and antiarrhythmic medications for stable VT. 1

Initial Assessment and Management

Hemodynamic Stability Assessment

• Unstable VT (signs include hypotension, acute altered mental status, chest pain, heart failure, or shock)

  • Immediate synchronized cardioversion (100J, 200J, 360J) with prior sedation if patient is conscious 2, 1
  • Position defibrillator paddles/pads at least 12-15cm away from implanted devices 1

• Stable VT (absence of severe symptoms)

  • Proceed with pharmacological management 2, 1

Pharmacological Management

For Stable VT

1. First-line medication: Lidocaine (Lignocaine)

   • Dosing: 50mg IV over 2 minutes, repeated every 5 minutes to total dose of 200mg 2
   • Maintenance: Start infusion at 2mg/min after successful conversion 2
   • Note: Lidocaine may cause myocardial depression, and toxic levels can produce paraesthesia, drowsiness, or seizures 2

2. Alternative medications:

   • Amiodarone: 150mg IV over 10 minutes, followed by infusion of 1mg/min for 6 hours, then 0.5mg/min for 18 hours 1

     • Particularly useful in patients with severe heart failure or acute MI 1
     • FDA-approved for VT refractory to other therapy 3

   • Procainamide: Loading infusion of 20-30mg/min up to 12-17mg/kg, followed by infusion of 1-4mg/min 1

     • FDA-approved for documented life-threatening ventricular arrhythmias 4

   • Magnesium: Consider for VT associated with acute myocardial infarction

     • Dosing: 8mmol bolus injection followed by 2.5mmol/h infusion 2

For Pulseless VT

• Follow VF protocol with immediate defibrillation as the primary intervention 2
• Antiarrhythmic drugs are secondary to defibrillation 2

Long-term Management

1. Implantable Cardioverter-Defibrillator (ICD)

   • Recommended for patients with structural heart disease who experienced VT with hemodynamic compromise 5
   • Superior to antiarrhythmic drugs for improving overall survival 5

2. Catheter Ablation

   • Consider for recurrent VT episodes, especially in specialized centers 1
   • Reasonable first-line option for idiopathic VT (structurally normal heart) 5

3. Maintenance Therapy

   • Oral beta-blockers should be administered during hospital stay and continued thereafter in all patients without contraindications 1
   • Consider chronic oral antiarrhythmic therapy with amiodarone, beta-blockers, or sotalol 1

Special Considerations

• Electrolyte Management: Correct electrolyte abnormalities, particularly potassium and magnesium 1
• Ischemia Evaluation: Consider urgent coronary angiography within 2 hours if acute coronary syndrome is suspected 1
• Drug-Induced VT: Withdraw any potential offending agents 1
• Monitoring: Continuous cardiac monitoring for at least 24-48 hours is essential 1

Pitfalls and Caveats

• Do not delay cardioversion in unstable patients 1
• Avoid sodium channel-blocking drugs in patients with history of myocardial infarction or structural heart disease 1
• For patients with pre-excited AF (Wolff-Parkinson-White syndrome), avoid AV nodal blocking agents as they may accelerate conduction through accessory pathway 1
• Antiarrhythmic drugs have not been shown to enhance survival in patients with ventricular arrhythmias 4
• Be aware that procainamide has potential to produce serious hematological disorders (0.5%), particularly leukopenia or agranulocytosis 4