From the Guidelines
For a patient in ventricular tachycardia (VTach) who is hemodynamically unstable, immediate synchronized cardioversion is the recommended treatment, starting at 100J and increasing as needed, as stated in the 2015 ESC guidelines 1. This approach is crucial because VTach can compromise cardiac output and deteriorate to ventricular fibrillation and cardiac arrest, making rapid intervention critical to prevent further hemodynamic compromise. The key considerations in managing VTach include:
- Hemodynamic stability: unstable patients require immediate cardioversion, while stable patients may be treated with anti-arrhythmic medications.
- Underlying causes: correcting electrolyte abnormalities, ischemia, or drug toxicity is essential to prevent recurrence.
- Continuous cardiac monitoring: essential throughout treatment to quickly identify any changes in the patient's condition. Alternative medications, such as procainamide or amiodarone, may be considered for stable patients or those who do not respond to cardioversion, as recommended in the 2006 ACC/AHA/ESC guidelines 1 and the 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science 1. However, the most recent and highest-quality evidence supports cardioversion as the first-line treatment for hemodynamically unstable patients 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. 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)
For a patient in ventricular tachycardia (VTach) who is hemodynamically unstable, the recommended treatment is:
- Amiodarone (IV), with a starting dose of about 1000 mg over the first 24 hours of therapy
- 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 2, 2
From the Research
Management of Hemodynamically Unstable Ventricular Tachycardia (VTach)
For a patient in ventricular tachycardia (VTach) who is hemodynamically unstable, the following management strategies are recommended:
- Electrical cardioversion should be applied as the first line of treatment 3
- In case of recurrences, pharmacological treatment with class I antiarrhythmic drugs or amiodarone may be considered 3
- The use of direct current cardioversion is most efficacious for the treatment of hemodynamically unstable VT 4
Comparison of Antiarrhythmic Drugs
The effectiveness of different antiarrhythmic drugs for the termination of sustained stable ventricular tachycardia has been compared in several studies:
- Procainamide and amiodarone have been shown to be relatively ineffective and associated with clinically important proportions of patients with decreased blood pressure 5
- Class IC antiarrhythmic drugs like flecainide and propafenon or ajmaline (class IA/IC) are very effective for the treatment of stable hemodynamically tolerable ventricular tachycardia 6
- Sotalol is also effective, however, caution is advised because of its significant beta-sympatholytic properties 6
Refractory Ventricular Tachycardia
In cases of refractory ventricular tachycardia, understanding how to rapidly diagnose, treat, and utilize second or third-line treatments is vital:
- Electrical storm, defined as three or more episodes of sustained VT, ventricular fibrillation, or appropriate shocks from an implantable cardioverter defibrillator within 24 hours, has a mortality rate up to 14% in the first 48 hours 7
- Appreciation for what medications are readily available in the crash cart and medication dispensing cabinet is critical for timely management of refractory ventricular tachycardia 7