What is the management algorithm for ventricular tachycardia (VT)?

Management Algorithm for Ventricular Tachycardia

The management of ventricular tachycardia (VT) should be guided by the patient's hemodynamic stability, with immediate direct current cardioversion recommended for patients presenting with sustained VT and hemodynamic instability. 1

Initial Assessment and Stabilization

• Determine hemodynamic stability - assess for hypotension, altered mental status, chest pain, heart failure, or shock 1
• Obtain 12-lead ECG for all patients with sustained VT who present in hemodynamically stable condition 1
• Presume wide-QRS tachycardia to be VT if the diagnosis is unclear 1

Management of Hemodynamically Unstable VT

• Immediate direct current cardioversion is the first-line treatment for patients with sustained VT and hemodynamic instability 1
• For patients who are hypotensive but conscious, provide immediate sedation before cardioversion 1
• If VT is refractory to standard cardioversion, consider double sequential synchronized cardioversion to avoid medications that may worsen hypotension 2
• Begin CPR if patient becomes unresponsive with no breathing or only occasional gasps 1

Management of Hemodynamically Stable VT

Monomorphic VT

• Electrical cardioversion should be the first-line approach even in hemodynamically stable patients 1
• If medical management is chosen:
  • Intravenous procainamide is recommended as first-line therapy (10 mg/kg at 50-100 mg/min IV over 10-20 min) with monitoring of blood pressure and ECG 1, 3
  • Avoid procainamide in patients with severe heart failure or acute myocardial infarction 1
  • Intravenous amiodarone (150 mg over 10 minutes, maximum dose 2.2 g/24 hours) may be considered in patients with heart failure or suspected ischemia 1, 4
  • Intravenous lidocaine is only moderately effective and should be considered second-line therapy, though it may be reasonable for initial treatment of VT specifically associated with acute myocardial ischemia 1
  • Calcium channel blockers such as verapamil and diltiazem should NOT be used to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction 1

Polymorphic VT

• Direct current cardioversion with appropriate sedation is recommended for patients with sustained polymorphic VT with hemodynamic compromise 1
• Intravenous beta blockers are useful for patients with recurrent polymorphic VT, especially if ischemia is suspected 1
• Intravenous amiodarone loading is useful for patients with recurrent polymorphic VT in the absence of abnormal repolarization related to congenital or acquired long QT syndrome 1

Special Considerations

• For LV fascicular VT (RBBB morphology and left axis deviation), intravenous verapamil or beta-blockers should be given 1
• For Purkinje-fiber triggered polymorphic VT refractory to drug treatment, catheter ablation may be considered 1

Long-term Management

• Urgent catheter ablation is recommended in patients with scar-related heart disease presenting with incessant VT or electrical storm 1
• Catheter ablation is recommended in patients with ischemic heart disease and recurrent ICD shocks due to sustained VT 1
• Catheter ablation should be considered after a first episode of sustained VT in patients with ischemic heart disease and an ICD 1
• For patients with sustained VT and a structurally normal heart (idiopathic VT), radiofrequency catheter ablation is a reasonable option 5
• Implantable cardioverter-defibrillator (ICD) is superior to antiarrhythmic drugs for improving overall survival in patients with underlying heart disease and ventricular fibrillation or sustained symptomatic VT with hemodynamic compromise 5

Monitoring and Support

• Post-cardiac arrest monitoring and support should include 12-lead ECG, assessment of perfusion/reperfusion, oxygenation and ventilation, temperature control, and addressing reversible causes 1
• When administering amiodarone, use a volumetric infusion pump and, whenever possible, administer through a central venous catheter dedicated to that purpose 4
• For infusions longer than 1 hour, do not exceed amiodarone concentrations of 2 mg/mL unless a central venous catheter is used to avoid peripheral vein phlebitis 4