What is the management of monomorphic Ventricular Tachycardia (VT)?

Management of Monomorphic Ventricular Tachycardia

Direct-current cardioversion with appropriate sedation is recommended at any point in the treatment cascade in patients with suspected sustained monomorphic VT with hemodynamic compromise. 1

Initial Assessment and Management Algorithm

Hemodynamic Status Assessment

• Any wide-QRS tachycardia should be presumed to be VT if the diagnosis is unclear 1
• Immediately determine if the patient is hemodynamically stable or unstable 1

For Hemodynamically Unstable Monomorphic VT

• Immediate direct-current cardioversion with appropriate sedation 1
• If VT recurs after cardioversion, consider:
  • Intravenous amiodarone (loading dose of 150 mg over 10 minutes, followed by maintenance infusion) 1, 2
  • Correction of potentially causative factors (hypokalemia, ischemia) 1

For Hemodynamically Stable Monomorphic VT

First-line Treatment:

• Intravenous procainamide (10 mg/kg at 50-100 mg/min) is reasonable for initial treatment 1, 3
  • Monitor blood pressure and ECG during administration
  • Class IIa recommendation with Level of Evidence B

Second-line Treatments:

• Intravenous amiodarone for VT that is refractory to conversion with countershock or recurrent despite procainamide 1, 2
  • Initial loading dose: 150 mg over 10 minutes
  • Maintenance: 1 mg/min for 6 hours, then 0.5 mg/min 2
• Transvenous catheter pace termination for VT refractory to cardioversion or frequently recurrent despite medication 1

Special Circumstances:

• For VT associated with acute myocardial ischemia/infarction:
  • Intravenous lidocaine (1 mg/kg initial bolus, followed by 0.5 mg/kg every 8-10 minutes if needed) 1, 4
  • Consider urgent coronary angiography with revascularization 1

Important Caveats and Contraindications

• Do not use calcium channel blockers (verapamil, diltiazem) to terminate wide-QRS-complex tachycardia of unknown origin, especially with history of myocardial dysfunction 1
• For repetitive monomorphic VT in coronary disease or idiopathic VT, consider combination therapy with:
  • Intravenous amiodarone
  • Beta blockers
  • Intravenous procainamide 1, 5
• Patients with low-level elevations in cardiac biomarkers should be treated similarly to those without biomarker rise 1

Long-term Management Considerations

• Consider catheter ablation for recurrent monomorphic VT, particularly in patients with structural heart disease 6
• Evaluate for implantable cardioverter-defibrillator (ICD) placement in appropriate patients with structural heart disease 7
• Left ventricular ejection fraction is frequently used to stratify patients at risk of sudden death who may benefit from prophylactic defibrillator 7

Treatment of Refractory Cases

• For VT resistant to standard therapies, consider:
  • Combination therapy with multiple antiarrhythmic agents 5
  • Low-dose intravenous epinephrine (0.5-1 mg administered over 30-60 seconds) has been reported as effective in case studies of refractory VT 8
• Hemodynamically unstable patients with recurrent VT may require mechanical circulatory support while definitive treatment is pursued 7, 9