What are the treatment approaches for sustained vs non-sustained Ventricular Tachycardia (VTach)?

Treatment Approaches for Sustained vs Non-Sustained Ventricular Tachycardia

For sustained ventricular tachycardia, immediate electrical cardioversion is the treatment of choice for hemodynamically unstable patients, while pharmacological therapy with procainamide is first-line for stable patients. 1, 2

Sustained Ventricular Tachycardia

Hemodynamically Unstable Sustained VT

• Immediate synchronized direct-current cardioversion with appropriate sedation is recommended (Class I recommendation) 1, 2
• Start with 100-200 J for monomorphic VT 2
• For polymorphic VT, use unsynchronized defibrillation at 200 J (treat similar to VF) 2
• After cardioversion, consider intravenous amiodarone for recurrent episodes 1, 3

Hemodynamically Stable Sustained VT

• Intravenous procainamide is first-line treatment (Class IIa recommendation) 1, 2, 4
  • Administer at 20-30 mg/min up to maximum dose of 10 mg/kg 5
  • Monitor blood pressure and ECG during administration 5
• Intravenous amiodarone is reasonable for patients with:
  • Heart failure 1
  • VT refractory to cardioversion 1, 3
  • Recurrent episodes despite procainamide 1
• Intravenous lidocaine might be reasonable if VT is associated with acute myocardial ischemia (Class IIb recommendation) 1
• Transvenous catheter pace termination can be useful for VT refractory to cardioversion or frequently recurrent despite medication 1, 2

Special Considerations for Sustained VT

• For polymorphic VT:
  • Intravenous beta-blockers are useful, especially if ischemia is suspected 1
  • Intravenous amiodarone is useful in absence of QT prolongation 1
  • Urgent angiography should be considered when myocardial ischemia cannot be excluded 1
• For recurrent sustained VT or electrical storm:
  • Radiofrequency catheter ablation at specialized center followed by ICD implantation should be considered 1, 2
  • Correction of electrolyte imbalances is recommended 1

Non-Sustained Ventricular Tachycardia

• Non-sustained VT (NSVT) occurs frequently in patients with acute coronary syndromes and rarely requires specific treatment 1
• For hemodynamically relevant NSVT, amiodarone (300 mg IV bolus) should be considered 1
• Prolonged and frequent ventricular ectopy can indicate need for further revascularization 1
• Beta-blocker treatment is recommended to prevent ventricular arrhythmias in patients with acute coronary syndromes 1
• Prophylactic treatment with other anti-arrhythmic drugs has not proven beneficial and may be harmful 1

Long-term Management Considerations

For Sustained VT

• ICD evaluation for patients with structural heart disease and sustained VT (high risk of recurrence and sudden death) 2, 6
• For sustained VT with severe hemodynamic compromise, ICD therapy is a Class I recommendation 1
• For sustained VT without hemodynamic compromise:
  • If LVEF ≤40%: ICD therapy is Class IIb recommendation 1
  • If LVEF >40%: ICD therapy is Class III recommendation (not indicated) 1

For Non-Sustained VT

• For NSVT ≥4 days after MI with LVEF ≤40% and inducible VF/sustained VT on EP study: ICD therapy is Class IIb recommendation 1
• For patients at high risk awaiting cardiac transplantation and those with hypertrophic cardiomyopathy with syncope/family history of sudden death: ICD therapy is Class III recommendation 1

Common Pitfalls to Avoid

• Do not use calcium channel blockers (verapamil, diltiazem) for wide-QRS tachycardia of unknown origin, especially with history of myocardial dysfunction 1, 5
• Do not delay cardioversion in hemodynamically unstable patients 5
• Do not use prophylactic anti-arrhythmic drugs (other than beta-blockers) in patients with acute coronary syndromes 1
• Avoid procainamide in patients with significant QT prolongation or heart failure 5

Diagnostic Considerations

• Any wide-QRS tachycardia should be presumed to be VT if diagnosis is unclear 1, 2
• Obtain 12-lead ECG for hemodynamically stable patients 2
• Classify VT as monomorphic (consistent QRS morphology) or polymorphic (changing QRS morphology) 2