What is the treatment for ventricular tachycardia with atrioventricular (AV) block?

Treatment for Ventricular Tachycardia with Atrioventricular Block

Synchronized cardioversion should be performed as the first-line treatment for ventricular tachycardia (VT) with atrioventricular (AV) block, especially in hemodynamically unstable patients, as this condition represents a potentially life-threatening arrhythmia requiring immediate intervention. 1

Initial Management Algorithm

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion is the treatment of choice for hemodynamically unstable VT with AV block 1
• Cardioversion should be performed promptly to restore sinus rhythm and prevent progression to ventricular fibrillation 1
• Prepare for potential cardiac resuscitation during the procedure 2

Hemodynamically Stable Patients

1. Synchronized cardioversion remains the most effective intervention even in stable patients with VT and AV block 1
2. Antiarrhythmic medications if cardioversion is delayed or as adjunctive therapy:
   • Intravenous amiodarone (150 mg over 10 minutes, followed by continuous infusion) may be considered, but monitor closely for:
     • Hypotension (occurs in 16% of patients) 2
     • Worsening bradycardia or AV block (occurs in 4.9% of patients) 2
     • QT prolongation and risk of torsades de pointes 2
   • Intravenous procainamide may be beneficial in stable patients 1
     • Contraindicated in patients with complete heart block 3
     • Monitor for QT prolongation 3

Special Considerations

AV Block Management

• Temporary pacing may be necessary to manage the AV block component 2
• Treat patients with known predisposition to bradycardia or AV block in a setting where temporary pacing is available 2
• Monitor for worsening of AV block during antiarrhythmic therapy 2

Post-Cardioversion Care

• Monitor for immediate post-cardioversion premature complexes that may trigger recurrence 1
• Consider prophylactic antiarrhythmic therapy to prevent immediate reinitiation of tachycardia 1
• Continuous ECG monitoring is essential during and after treatment 4

Long-Term Management

• Catheter ablation has shown superior outcomes compared to antiarrhythmic drugs for symptomatic VT in patients with ischemic cardiomyopathy 5
• If ablation is not feasible, consider:
  • Amiodarone (with careful monitoring for long-term toxicity) 6, 7
  • Sotalol for patients without structural heart disease 4, 8
  • Beta-blockers as adjunctive therapy 6, 5

Important Caveats

• Never use calcium channel blockers (verapamil, diltiazem) in VT with AV block as they can worsen the condition by further depressing AV conduction and causing hemodynamic collapse 1, 9
• Avoid adenosine in confirmed VT as it is ineffective and may worsen the arrhythmia 1, 9
• Monitor electrolytes (especially potassium, magnesium, and calcium) as imbalances can exacerbate arrhythmias and increase the risk of torsades de pointes 2
• Continuous ECG monitoring is essential during treatment to detect worsening of the arrhythmia or AV block 2, 4