From the Guidelines
Acute ventricular tachycardia (VTach) requires immediate treatment based on the patient's hemodynamic stability, with direct current cardioversion being the first-line treatment for patients presenting with sustained VT and haemodynamic instability, as recommended by the European Society of Cardiology (ESC) guidelines 1. For unstable patients with symptoms like hypotension, chest pain, or altered mental status, immediate synchronized cardioversion at 100-200 joules is the first-line treatment. The following key points are essential in the management of VTach:
- For stable patients, intravenous antiarrhythmic medications are preferred, with amiodarone 150 mg IV over 10 minutes followed by an infusion of 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours being the most common choice, as supported by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines 1.
- Alternative medications include procainamide (20-50 mg/min IV until arrhythmia suppression, hypotension, QRS widening, or maximum 17 mg/kg) or lidocaine (1-1.5 mg/kg IV bolus, followed by 0.5-0.75 mg/kg every 5-10 minutes if needed, maximum 3 mg/kg).
- Underlying causes such as electrolyte abnormalities, ischemia, or medication toxicity must be identified and corrected.
- Oxygen should be administered, IV access established, and continuous cardiac monitoring maintained throughout treatment.
- VTach is dangerous because it prevents effective cardiac output, potentially leading to cardiac arrest if not promptly treated.
- After acute management, patients typically require electrophysiology consultation for long-term management strategies, which may include implantable cardioverter-defibrillators for those at high risk of recurrence. The most recent and highest quality study, the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, provides the foundation for the management of VTach, emphasizing the importance of prompt treatment based on hemodynamic stability.
From the FDA Drug Label
Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. The recommended starting dose of amiodarone is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone (mixed in 100 mL of D5W and infused over 10 minutes to minimize the potential for hypotension)
The treatment for acute Ventricular Tachycardia (VTach) is amiodarone (IV), with a recommended starting dose of about 1000 mg over the first 24 hours of therapy.
- The dose regimen consists of an initial rapid loading infusion, followed by a slower loading infusion, and then a maintenance infusion.
- Supplemental infusions of 150 mg amiodarone may be given for breakthrough episodes of VT/VF. 2 2
From the Research
Treatment Options for Acute Ventricular Tachycardia (VTach)
- The treatment for acute VTach depends on the hemodynamic stability of the patient 3, 4, 5.
- For hemodynamically stable patients, antiarrhythmic drugs such as class I antiarrhythmic drugs (e.g., lidocaine, ajmaline, procainamide) or amiodarone can be used 3, 4, 5, 6, 7.
- Procainamide has been shown to be effective in terminating stable VT, with a maximum dose of 10 mg/kg at 50-100 mg/min intravenous (IV) over 10-20 min 4, 6.
- Amiodarone is also commonly used, but its efficacy has been questioned in some studies 6, 7.
- For hemodynamically unstable patients, electrical cardioversion is the preferred treatment 3, 4, 5.
Comparison of Treatment Options
- A study comparing procainamide and amiodarone found that procainamide was not more effective than amiodarone for the termination of sustained VT, but the study had limitations 6.
- Another study found that approximately half of patients treated with amiodarone reverted from VT while under paramedic care, with rare cases of patient deterioration 7.
- The American Heart Association provides a IIa recommendation for procainamide, compared with a IIb recommendation for both amiodarone and sotalol 4.