What is the treatment for ventricular tachycardia (VTach)?

Treatment for Ventricular Tachycardia

The treatment for ventricular tachycardia (VT) must be based on hemodynamic stability, with immediate synchronized cardioversion for unstable patients and procainamide as first-line pharmacological therapy for stable monomorphic VT. 1, 2

Initial Assessment and Management Based on Hemodynamic Status

Hemodynamically Unstable VT

• Immediate synchronized DC cardioversion starting at 100J, increasing to 200J and then 360J if needed 1, 2
• Sedate the patient before cardioversion if conscious but unstable 1
• For pulseless VT, follow VF protocol with immediate defibrillation 1
• In cases of in-hospital cardiac arrest due to VT, immediate defibrillation should be attempted 2

Hemodynamically Stable Monomorphic VT

• Procainamide is the first-line pharmacological treatment (10-20 mg/kg IV at 50-100 mg/min over 10-20 minutes) 1, 2
• Monitor for hypotension and QRS widening during procainamide administration 1
• Alternative medications include:
  • Amiodarone - particularly useful for patients with heart failure or suspected ischemia 2, 3
  • Lidocaine - less effective than procainamide, sotalol, or amiodarone 1, 2
  • Sotalol - can be considered for stable monomorphic VT, including in patients with acute MI 2, 4

Special Considerations for Specific Types of VT

Polymorphic VT

• For polymorphic VT with normal QT interval (possibly ischemia-related): Consider IV beta-blockers 1
• For polymorphic VT with long QT syndrome: IV magnesium (8 mmol bolus followed by 2.5 mmol/h infusion) 1
• For catecholaminergic polymorphic VT: Beta-blockers are the cornerstone of treatment 1, 2

VT in Specific Clinical Scenarios

• For VT during acute myocardial infarction: Consider sotalol or beta-blockers 2
• For incessant VT or electrical storm in patients with scar-related heart disease: Urgent catheter ablation 2
• For familial long QT syndrome: Pacing and beta-blockers, avoiding isoproterenol 1

Long-term Management After Acute Episode

• Consider ICD implantation for secondary prevention in patients with structural heart disease 1
• Catheter ablation may be indicated for recurrent VT, especially in patients with ischemic heart disease 1, 2
• For patients with catecholaminergic polymorphic VT who have recurrent sustained VT or syncope despite beta-blocker therapy, consider combination therapy with flecainide, left cardiac sympathetic denervation, and/or ICD 2

Common Pitfalls and Caveats

• Lidocaine is less effective than procainamide, sotalol, or amiodarone for stable VT 1, 2
• Amiodarone's antiarrhythmic effect may take up to 30 minutes, making it less suitable for emergent situations 1, 2
• For patients with an ICD, defibrillator patches should be placed on the chest wall at least 8 cm from the generator position 2
• Sotalol can cause life-threatening ventricular tachycardia associated with QT interval prolongation; initiate or uptitrate in a facility that can provide continuous ECG monitoring and cardiac resuscitation 4
• Do not initiate sotalol therapy if the baseline QTc is longer than 450 ms; if the QTc prolongs to 500 ms or greater, reduce the dose or discontinue 4