What is the management of ventricular tachycardia (Vtach)?

Management of Ventricular Tachycardia (VTach)

Direct current cardioversion is the first-line treatment for patients presenting with sustained ventricular tachycardia and hemodynamic instability. 1

Initial Assessment and Management

Hemodynamically Unstable VTach

• Immediate synchronized direct current cardioversion is recommended for patients with VTach who are hemodynamically unstable (presenting with hypotension, altered mental status, or signs of shock) 1
• In patients who are hypotensive yet conscious, immediate sedation should be given before cardioversion 1
• For polymorphic VT that appears similar to VF, use unsynchronized discharge of 200 J 1
• For monomorphic VT with rates greater than 150 bpm, use 100 J synchronized discharge 1

Hemodynamically Stable VTach

• Electrical cardioversion should be the first-line approach even in hemodynamically stable patients with wide complex tachycardia 1, 2
• If pharmacological therapy is chosen for stable monomorphic VT, consider the following options:

Medication Options for Stable VTach:

• Intravenous procainamide: 20-30 mg/min loading infusion up to 12-17 mg/kg, followed by infusion of 1-4 mg/min (reduce in renal dysfunction) 1, 2
• Intravenous amiodarone: 150 mg infused over 10 minutes followed by constant infusion of 1.0 mg/min for 6 hours and then maintenance infusion at 0.5 mg/min 1, 3
• Intravenous lidocaine: bolus 1.0-1.5 mg/kg with supplemental boluses of 0.5-0.75 mg/kg every 5-10 minutes to maximum 3 mg/kg total loading dose, followed by infusion of 2-4 mg/min (reduce in elderly, heart failure, or hepatic dysfunction) 1

Special Considerations

VTach in Context of Heart Failure or Ischemia

• Intravenous amiodarone is preferred in patients with heart failure or suspected myocardial ischemia 1
• Avoid calcium channel blockers (verapamil, diltiazem) in patients with VTach and structural heart disease as they may worsen hemodynamics 1

Fascicular VT

• Intravenous verapamil or beta-blockers should be given in patients presenting with left ventricular fascicular VT (characterized by right bundle branch block morphology and left axis deviation) 1

Post-Cardioversion Management

• After successful cardioversion, patients often have atrial or ventricular premature complexes that may trigger recurrent episodes of VTach 1
• Antiarrhythmic medication may be required to prevent acute reinitiation of tachycardia 1, 4
• Amiodarone is indicated for initiation of treatment and prophylaxis of frequently recurring VF and hemodynamically unstable VT in patients refractory to other therapy 3

Catheter Ablation Considerations

• 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

Common Pitfalls and Caveats

• Do not use calcium channel blockers (verapamil, diltiazem) for wide-complex tachycardias unless certain they are fascicular VT, as they may precipitate hemodynamic collapse in structural VT 1
• When using sotalol for VT management, continuous ECG monitoring is essential as it can cause life-threatening proarrhythmia associated with QT interval prolongation 5
• Do not initiate sotalol therapy if baseline QTc is longer than 450 ms; if QTc prolongs to 500 ms or greater, reduce the dose or discontinue 5
• Ensure potassium and magnesium levels are normalized before initiating antiarrhythmic therapy 5
• Most post-MI VT and VF occur within the first 48 hours; sustained VT or VF occurring outside this timeframe deserves careful evaluation, including consideration of electrophysiology studies 1