What is the management of polymorphic ventricular tachycardia (V-tach) with a pulse?

From the Guidelines

The management of polymorphic ventricular tachycardia (V-tach) with a pulse should prioritize intravenous beta-blocker treatment, unless contraindicated, as recommended by the 2017 ESC guidelines 1. This approach is based on the most recent and highest quality evidence available. The key steps in managing PMVT with a pulse include:

• Assessing and stabilizing the patient with supplemental oxygen and IV access
• Identifying and correcting underlying causes such as electrolyte abnormalities (particularly potassium and magnesium), drug toxicity, myocardial ischemia, or structural heart disease
• Discontinuing any QT-prolonging medications
• Considering urgent coronary angiography if ischemia is suspected
• Using intravenous amiodarone for treatment of recurrent polymorphic VT, as recommended by the 2017 ESC guidelines 1
• Correcting electrolyte imbalances, especially hypokalaemia and hypomagnesemia, as recommended by the 2017 ESC guidelines 1

The use of intravenous beta-blockers, such as metoprolol, can be effective in managing PMVT, particularly if ischemia or catecholaminergic triggers are present 1. However, the most recent guidelines from 2017 should take precedence in guiding treatment decisions. It is essential to prioritize the patient's hemodynamic stability and correct any underlying causes of the arrhythmia to prevent deterioration to cardiac arrest. The management of PMVT requires a comprehensive approach, including acute termination, ongoing management, and long-term management, with a focus on treating the underlying cause and optimizing heart failure therapy if applicable.

In cases where PMVT is suspected to be caused by torsades de pointes, temporary overdrive pacing may be necessary to increase heart rate and suppress the arrhythmia. However, the primary focus should be on correcting the underlying cause of the arrhythmia and preventing recurrence. The 2017 ESC guidelines provide the most up-to-date recommendations for managing PMVT, and their recommendations should be followed in clinical practice 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 management of polymorphic ventricular tachycardia (V-tach) with a pulse is not directly addressed in the provided drug labels.

• The labels discuss the treatment of hemodynamically unstable VT, but do not provide specific guidance on polymorphic V-tach with a pulse.
• The labels recommend a starting dose of 1000 mg over the first 24 hours for the treatment of VT/VF, but do not specify the management of polymorphic V-tach with a pulse 2, 2.
• Clinical studies have demonstrated the effectiveness of intravenous amiodarone in suppressing recurrent VF or hemodynamically unstable VT, but do not provide direct guidance on the management of polymorphic V-tach with a pulse 2.

From the Research

Management of Polymorphic Ventricular Tachycardia (V-tach) with a Pulse

• The management of polymorphic ventricular tachycardia (V-tach) with a pulse is complex and requires careful consideration of the underlying cause and the patient's hemodynamic status 3.
• Polymorphic V-tach is a highly lethal arrhythmia that can be caused by various factors, including structural heart disease and acquired conditions 4.
• The treatment of polymorphic V-tach depends on the specific type and underlying cause, and medications that are effective for one type may be contraindicated for another 3.
• In general, the management of stable ventricular tachycardia, including polymorphic V-tach, involves the use of antiarrhythmic medications, while unstable ventricular tachycardia requires immediate cardioversion 5.
• Procainamide has been shown to be effective in the treatment of stable monomorphic ventricular tachycardia, but its use in polymorphic V-tach is not well established 6.
• Amiodarone is often used to treat ventricular tachyarrhythmias, but it can also have a proarrhythmic effect and induce incessant monomorphic ventricular tachycardia 7.

Key Considerations

• The diagnosis and management of polymorphic V-tach require a thorough understanding of the underlying cause and the patient's hemodynamic status 3, 4.
• The use of antiarrhythmic medications should be guided by the specific type of ventricular tachycardia and the patient's underlying condition 6, 5.
• Close monitoring of the patient's electrocardiogram and hemodynamic status is essential during the treatment of ventricular tachycardia 6, 5.