What is the management of stable ventricular tachycardia?

Management of Stable Ventricular Tachycardia

Direct current cardioversion with appropriate sedation is the first-line treatment for patients with stable sustained monomorphic ventricular tachycardia (VT). 1

Initial Assessment and Approach

• Wide-QRS tachycardia should be presumed to be VT if the diagnosis is unclear 1
• A 12-lead ECG should be recorded for all patients with sustained VT who present in a hemodynamically stable condition 1
• Assess for and correct potentially causative or aggravating conditions such as hypokalemia and myocardial ischemia 1

Treatment Algorithm for Stable Monomorphic VT

First-Line Treatment:

• Direct current synchronized cardioversion with appropriate sedation 1
  • This is the most efficacious approach and should be considered at any point in the treatment cascade 1, 2

Pharmacological Management (if cardioversion is delayed or deferred):

For patients WITHOUT severe heart failure or acute myocardial infarction:

• Intravenous procainamide (Class IIa recommendation) 1
  • Dosage: 10 mg/kg at 50-100 mg/min IV over 10-20 minutes 1, 2
  • Monitor blood pressure and ECG during administration 2
  • Most appropriate when early slowing of VT rate and termination are desired 1

For patients WITH heart failure or suspected ischemia:

• Intravenous amiodarone (Class IIa recommendation) 1
  • Initial loading: 150 mg IV over 10 minutes 1, 3
  • Follow with infusion of 1 mg/min for 6 hours, then 0.5 mg/min maintenance 3
  • Indicated for VT that is hemodynamically unstable, refractory to conversion with countershock, or recurrent despite other agents 1, 3

For VT specifically associated with acute myocardial ischemia:

• Intravenous lidocaine (Class IIb recommendation) 1
  • Dosage: 1-1.5 mg/kg IV bolus 1
  • Note: Less effective than procainamide or amiodarone for most VT cases 2, 4

For Refractory Cases:

• Transvenous catheter pace termination for VT that is refractory to cardioversion or frequently recurrent despite medication 1
• Urgent catheter ablation for patients with scar-related heart disease presenting with incessant VT 1

Special Considerations for Polymorphic VT

• Direct current cardioversion (unsynchronized if unstable) 1
• Intravenous beta-blockers are useful, especially if ischemia is suspected 1
• Intravenous amiodarone loading is useful in the absence of long QT syndrome 1
• Urgent angiography with revascularization should be considered when myocardial ischemia cannot be excluded 1

Important Cautions

• Calcium channel blockers (verapamil, diltiazem) should NOT be used to terminate wide-QRS-complex tachycardia of unknown origin, especially in patients with myocardial dysfunction 1
• For LV fascicular VT (RBBB morphology with left axis deviation), intravenous verapamil or beta-blockers may be appropriate 1
• Amiodarone concentrations >2 mg/mL should be administered through a central venous catheter to avoid peripheral vein phlebitis 3
• Combination therapy with amiodarone and Class I agents rarely suppresses VT inducibility but may render VT hemodynamically stable by slowing the rate 5

Long-term Management

• Consider ICD placement for secondary prevention of sudden cardiac death 6
• Catheter ablation is recommended for patients with ischemic heart disease and recurrent ICD shocks due to sustained VT 1
• Long-term oral amiodarone may be effective in 69% of patients with refractory VT but carries significant toxicity risks in approximately 50% of patients 7