From the Guidelines
Ventricular tachycardia (VTach) treatment should prioritize catheter ablation, especially in patients with left ventricular dysfunction and sustained VT, as it has been shown to decrease the rate of recurrent electrical storm episodes and improve outcomes 1.
Treatment Approach
The treatment approach for VTach should be based on the patient's hemodynamic stability. For unstable patients, immediate defibrillation and CPR are necessary. For hemodynamically stable patients, antiarrhythmic medications such as amiodarone, lidocaine, or procainamide can be administered. However, catheter ablation is recommended for patients with recurrent ICD shocks due to sustained VT, as it has been shown to be effective in preventing VT recurrences 1.
Catheter Ablation
Catheter ablation has been shown to be effective in treating VTach, especially in patients with left ventricular dysfunction and sustained VT. The Multicenter Thermocool study reported an acute success rate of 49% and a mid-term freedom from VT of 53% over 6 months of follow-up 1. Additionally, the Euro-VT study reported an acute success rate of 81% and freedom from recurrent VT in 51% of patients 1.
Antiarrhythmic Medications
Antiarrhythmic medications such as amiodarone, lidocaine, and procainamide can be used to treat VTach. Amiodarone is recommended for patients with HF or suspected ischemia, while procainamide and flecainide may be considered for those who do not present with severe HF or acute myocardial infarction 1. However, catheter ablation is preferred over medical treatment for patients with recurrent VTach 1.
Implantable Cardioverter-Defibrillator (ICD) Placement
ICD placement is recommended for patients undergoing catheter ablation whenever they satisfy eligibility criteria for ICD. ICD implantation is recommended in patients with left ventricular dysfunction and sustained VT, as it has been shown to improve survival and reduce the risk of sudden cardiac death 1.
Underlying Causes
Correcting underlying causes such as electrolyte abnormalities, ischemia, or drug toxicity is essential in the treatment of VTach. Magnesium sulfate is particularly useful for torsades de pointes, a specific form of VTach 1.
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 is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: Initial Load: 150 mg in 100 mL (in D 5W) infused over 10 minutes Followed by: 1 mg/min for 6 hours Followed by: 0.5 mg/min thereafter For breakthrough episodes of VF or hemodynamically unstable VT, repeat the Initial Load.
The treatment for Ventricular Tachycardia (VTach) is amiodarone (IV), with a recommended starting dose of about 1000 mg over the first 24 hours of therapy. The infusion regimen consists of an initial load of 150 mg in 100 mL (in D5W) infused over 10 minutes, followed by 1 mg/min for 6 hours, and then 0.5 mg/min thereafter. For breakthrough episodes of VT, the initial load can be repeated 2, 2.
From the Research
Treatment Options for Ventricular Tachycardia (VTach)
- For the emergency treatment of sustained, hemodynamically stable ventricular tachycardia, antiarrhythmic drugs are the therapy of choice, with class I antiarrhythmic drugs such as lidocaine or ajmaline being preferred 3.
- In hemodynamically unstable ventricular tachycardia, electrical cardioversion should be applied, followed by pharmacological treatment with class I antiarrhythmic drugs or amiodarone in case of recurrences 3.
- Catheter ablation is an alternative or adjunctive option for treating ventricular tachycardia, especially in patients with antiarrhythmic drug-refractory VT and previous myocardial infarction, as it improves ventricular tachycardia event-free survival and reduces ICD therapy burden 4, 5, 6.
- Amiodarone is associated with a significantly reduced rate of VT recurrence and ICD shocks compared to control, while sotalol is associated with increased risk of VT recurrence and ICD shocks 6.
- The acute management of patients with ventricular arrhythmia aims at immediate termination if the patient is hemodynamically unstable, and early termination after initial diagnostic work-up if tolerated, using electrical cardioversion, anti-tachycardia pacing, or defibrillation, and antiarrhythmic drug treatment for rhythm stabilization in cases of VA recurrence 7.
Pharmacological Treatment
- Class I antiarrhythmic drugs such as lidocaine or ajmaline are preferred for the emergency treatment of sustained, hemodynamically stable ventricular tachycardia 3.
- Amiodarone is effective in reducing VT recurrence and ICD shocks, but its long-term side effects should be weighed carefully according to specific patient characteristics 6.
- Sotalol is associated with increased risk of VT recurrence and ICD shocks compared to amiodarone, and its use should be carefully considered 6.
Non-Pharmacological Treatment
- Electrical cardioversion is the preferred method for terminating ventricular tachycardia in hemodynamically unstable patients 3, 7.
- Catheter ablation is a viable option for treating ventricular tachycardia, especially in patients with antiarrhythmic drug-refractory VT and previous myocardial infarction, as it improves ventricular tachycardia event-free survival and reduces ICD therapy burden 4, 5, 6.
- Implantable cardioverter-defibrillators (ICDs) can reduce the mortality risk associated with recurrent ventricular tachycardia, but do not prevent recurrent episodes, and their use should be considered in conjunction with other treatment options 5, 6.