What is the treatment for ventricular tachycardia (VT)?

Treatment of Ventricular Tachycardia

For ventricular tachycardia (VT), immediate electrical cardioversion is the first-line treatment for hemodynamically unstable patients, while procainamide is the preferred pharmacological agent for stable monomorphic VT without severe heart failure or acute myocardial infarction. 1, 2

Initial Assessment and Management

Hemodynamically Unstable VT

• Immediate synchronized DC cardioversion (100J, 200J, then 360J) 1, 3
• Follow with high-quality CPR if pulseless VT develops
• For pulseless VT, treat according to VF/pulseless VT protocol:
  • Immediate defibrillation (unsynchronized shock)
  • CPR for 2 minutes between rhythm checks
  • IV access for medication administration

Hemodynamically Stable VT

Monomorphic VT without severe heart failure or AMI:

1. Procainamide: 10 mg/kg IV at 50-100 mg/min over 10-20 minutes 1, 2

   • Monitor blood pressure and ECG during administration
   • Most effective pharmacological agent for terminating stable mVT

2. Amiodarone: If procainamide fails or is contraindicated

   • Initial dose: 150 mg IV over 10 minutes 1, 4
   • Follow with infusion: 1 mg/min for 6 hours, then 0.5 mg/min 4
   • FDA-approved for VF and hemodynamically unstable VT refractory to other therapy 4

3. Sotalol: Alternative for stable mVT including patients with AMI 1

   • Caution due to significant beta-blocking properties 5

4. Lidocaine: Less effective than other options 1, 2, 5

   • No longer recommended as first-line therapy

Monomorphic VT with severe heart failure or AMI:

• Amiodarone: Preferred agent 1
• Electrical cardioversion: Consider early if medication fails 1, 3

Polymorphic VT:

• With long QT syndrome: IV magnesium, pacing, and beta-blockers (avoid isoproterenol) 1
• With acquired long QT syndrome: IV magnesium, consider pacing or isoproterenol if bradycardia present 1
• Without long QT syndrome: IV beta-blockers (for ischemic or catecholaminergic VT) or isoproterenol 1

Prevention of Recurrence

• Amiodarone: Reduces recurrent episodes of symptomatic VT 1, 3

  • Loading dose: 300 mg IV, followed by maintenance infusion
  • Consider transition to oral therapy when stable

• Beta-blockers: Improve survival and reduce recurrent arrhythmias during electrical storm 1, 3

• ICD implantation: For patients with structural heart disease and sustained symptomatic VT 6

• Catheter ablation: Consider for scar-related VT, incessant VT, electrical storm, or recurrent ICD shocks 3

Special Considerations

• For refractory VT, consider addressing reversible causes (hypovolemia, hypoxia, electrolyte abnormalities) 3

• In patients with structurally normal hearts (idiopathic VT), radiofrequency catheter ablation is a reasonable option 6

• For VT during acute myocardial infarction, mortality risk is significantly higher (65% of unstable VT patients have AMI) 7

• Avoid multiple sequential antiarrhythmic drugs if initial therapy fails; proceed to electrical cardioversion 5

Common Pitfalls

1. Delaying electrical cardioversion in unstable patients
2. Using lidocaine as first-line therapy (less effective than procainamide or amiodarone)
3. Failing to monitor for hypotension during antiarrhythmic administration
4. Not considering underlying causes of VT (ischemia, electrolyte abnormalities)
5. Overlooking the need for long-term management strategies after acute stabilization

The treatment approach should be guided by the patient's hemodynamic status, the morphology of VT, and the presence of underlying structural heart disease, with the primary goal of reducing morbidity and mortality.