What are the medications used to manage ventricular tachycardia (VT)?

Medications for Ventricular Tachycardia Management

For stable monomorphic VT, intravenous procainamide is the preferred first-line antiarrhythmic medication, while amiodarone is reserved for hemodynamically unstable VT, refractory cases, or patients with heart failure. 1

Hemodynamic Status Determines Treatment Approach

Hemodynamically Unstable VT

• Direct current cardioversion with appropriate sedation is the definitive treatment and should be performed immediately 1
• If VT is refractory to cardioversion or recurs despite electrical therapy:
  • Intravenous amiodarone is the medication of choice (Class IIa recommendation) 1, 2
  • Loading dose: 150 mg IV over 10 minutes for breakthrough episodes, followed by maintenance infusion 1, 2
  • Amiodarone is specifically indicated for frequently recurring VF and hemodynamically unstable VT refractory to other therapy 2

Hemodynamically Stable Monomorphic VT

First-line pharmacologic options:

• Intravenous procainamide (Class IIa recommendation, Level B evidence) is the most appropriate agent for early slowing and termination 1

  • Maximum dose: 10 mg/kg at 50-100 mg/min IV over 10-20 minutes 3
  • Demonstrates greatest efficacy among antiarrhythmics for stable monomorphic VT 3, 4
  • Requires close monitoring of blood pressure and cardiovascular status, especially with heart failure or hypotension 1
  • Alternative in Europe: ajmaline 1

• Intravenous amiodarone is reasonable but not ideal for early conversion of stable monomorphic VT 1

  • Reserved for VT refractory to procainamide or other agents 1
  • First 24-hour dosing: approximately 1000 mg total (150 mg loading dose over 10 min, then 1 mg/min for 6 hours, then 0.5 mg/min maintenance) 2
  • Can be continued for 2-3 weeks if needed 2

• Intravenous lidocaine (Class IIb recommendation) may be reasonable specifically when VT is associated with acute myocardial ischemia or infarction 1

  • Dose: 1-3 mg/kg IV bolus (100 mg for cardiac arrest), may repeat after 5-10 minutes 1
  • Maintenance infusion: 2-4 mg/min 1

Polymorphic VT Management

The medication approach differs based on QT interval:

• Intravenous beta blockers (Class I recommendation, Level B evidence) are the primary medication for recurrent polymorphic VT, especially when ischemia is suspected or cannot be excluded 1

  • Beta blockers improve mortality in recurrent polymorphic VT with acute MI 1

• Intravenous amiodarone loading (Class I recommendation) is useful for recurrent polymorphic VT in the absence of QT prolongation 1

  • Do NOT use in torsades de pointes or congenital/acquired long QT syndrome 1

• Intravenous magnesium sulfate (Class IIa recommendation, Level A evidence for torsades) 1

  • Dose: 8 mmol bolus followed by 2.5 mmol/h infusion 1
  • Particularly effective for VF/VT associated with acute MI 1
  • Essential for torsades de pointes management 1

• Intravenous lidocaine (Class IIb) may be reasonable for polymorphic VT specifically with acute myocardial ischemia 1

Repetitive Monomorphic VT (Ongoing Management)

For repetitive episodes in the context of coronary disease or idiopathic VT (Class IIa recommendation):

• Intravenous amiodarone 1
• Beta blockers 1
• Intravenous procainamide (or sotalol/ajmaline in Europe) 1

Critical Contraindications

Calcium channel blockers (verapamil, diltiazem) should NOT be used (Class III recommendation) to terminate wide-QRS-complex tachycardia of unknown origin, especially with history of myocardial dysfunction 1

Important Clinical Considerations

• Always correct underlying conditions first: hypokalemia, ischemia, and other electrolyte abnormalities must be addressed as an early priority 1
• Wide-QRS tachycardia should be presumed to be VT if diagnosis is unclear (Class I recommendation) 1
• Procainamide shows approximately 30% termination rate versus 25% for amiodarone in stable VT, though both are relatively ineffective compared to cardioversion 4
• Hypotension occurs in approximately 6% of amiodarone patients and 19% of procainamide patients, requiring cessation or immediate cardioversion 4
• For VT associated with acute ischemia, urgent angiography with revascularization should be considered 1
• Transvenous catheter pace termination can be useful for VT refractory to cardioversion or frequently recurrent despite medications 1