What is the treatment for ventricular tachycardia?

Treatment of Ventricular Tachycardia

Immediate Management: Hemodynamic Status Determines Everything

For hemodynamically unstable VT (hypotension with systolic BP ≤90 mmHg, altered mental status, chest pain, acute heart failure, or heart rate ≥150 bpm), perform immediate synchronized direct current cardioversion starting at 100J, escalating to 200J then 360J if needed. 1, 2, 3 If the patient is hypotensive but conscious, provide immediate sedation before cardioversion. 1, 2 For pulseless VT, treat as ventricular fibrillation with immediate unsynchronized defibrillation at 200J. 2, 3

For polymorphic VT that resembles VF, use unsynchronized discharge of 200J; for monomorphic VT with rates >150 bpm, use 100J synchronized discharge. 3

Pharmacological Management for Stable Monomorphic VT

Procainamide is the first-line pharmacological agent for hemodynamically stable monomorphic VT, demonstrating the greatest efficacy among all antiarrhythmic drugs. 1, 2, 4 Administer 10 mg/kg IV at 50-100 mg/min over 10-20 minutes (maximum dose 10-20 mg/kg). 1, 2, 5 Monitor continuously for hypotension and QRS widening during administration—stop if QRS widens significantly. 2

Critical Contraindications to Procainamide

Avoid procainamide in patients with severe heart failure or acute myocardial infarction—use amiodarone instead. 2 Procainamide carries a risk of serious hematological disorders including leukopenia or agranulocytosis (0.5% incidence, sometimes fatal), so reserve it for patients where benefits clearly outweigh risks. 5

When to Use Amiodarone Instead

Amiodarone is preferred in patients with heart failure or suspected myocardial ischemia. 1, 3 Dosing: 150 mg (5 mg/kg) IV over 10 minutes, then 1 mg/min infusion for 6 hours, then 0.5 mg/min. 1 Amiodarone reduces life-threatening arrhythmias, required shocks, and episodes of symptomatic sustained VT. 1, 6 It is indicated for frequently recurring VF and hemodynamically unstable VT refractory to other therapy, with most patients requiring 48-96 hours of treatment. 6

Alternative Agent: Sotalol

Sotalol may be considered for hemodynamically stable sustained monomorphic VT, including patients with acute myocardial infarction, but exercise caution due to significant beta-sympatholytic properties. 1, 2

Special Considerations for Polymorphic VT

For polymorphic VT with normal QT interval (likely ischemia-related), consider IV beta-blockers and treat underlying ischemia aggressively. 2

For polymorphic VT with prolonged QT interval (Torsades de Pointes), administer IV magnesium sulfate: 8 mmol bolus followed by 2.5 mmol/h infusion, and correct electrolyte abnormalities (potassium, magnesium). 2

Critical Pitfalls to Avoid

Never assume wide-complex tachycardia is supraventricular—when in doubt, treat as VT. 2, 3 This is perhaps the most dangerous error in VT management.

Avoid calcium channel blockers (verapamil, diltiazem) in VT with structural heart disease, as they may precipitate hemodynamic collapse and worsen outcomes. 2, 3 Only use calcium channel blockers if you are certain the rhythm is fascicular VT. 3

Intravenous lidocaine is only moderately effective in VT and less effective than procainamide, sotalol, or amiodarone—it should not be first-line. 1

Management of Recurrent VT After Cardioversion

If VT recurs after cardioversion, administer antiarrhythmic drugs to prevent acute reinitiation. 1, 3 Beta-blockers may be useful for preventing recurrence and late conversion in refractory ventricular tachyarrhythmias. 1

Long-Term and Interventional Management

Urgent catheter ablation is recommended in patients with scar-related heart disease presenting with incessant VT or electrical storm. 1, 2, 3 Catheter ablation is also recommended in patients with ischemic heart disease and recurrent ICD shocks due to sustained VT, and should be considered after a first episode of sustained VT in patients with ischemic heart disease and an ICD. 1, 3

For catecholaminergic polymorphic VT, beta-blockers are the cornerstone of treatment. 1, 2 For recurrent sustained VT or syncope despite beta-blocker therapy, consider combination therapy with flecainide, left cardiac sympathetic denervation, and/or ICD. 1

Monitoring Requirements During Treatment

• Continuous ECG monitoring is mandatory for all VT treatment 2
• Measure and normalize serum potassium and magnesium before initiating antiarrhythmics 2
• Monitor QTc interval—discontinue drug if QTc prolongs to ≥500 ms 2
• The facility must have cardiac resuscitation capabilities immediately available 2
• For patients with an ICD, place defibrillator patches at least 8 cm from the generator position 1

Refractory Cases

If standard cardioversion fails, consider double sequential synchronized cardioversion, which may obviate the need for rapid infusion of medications like amiodarone that may worsen hypotension in the already unstable patient. 7