From the Guidelines
Acute ventricular tachycardia (VTach) should be treated with immediate synchronized cardioversion at 100-200 joules for unstable patients, while stable patients can be treated with intravenous antiarrhythmic medications as the first line of treatment. The treatment approach is based on the patient's hemodynamic stability, with unstable patients requiring immediate intervention to prevent further deterioration. According to the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, patients presenting with monomorphic VT and hemodynamic instability should undergo direct cardioversion.
For stable patients, intravenous antiarrhythmic medications such as amiodarone, procainamide, or lidocaine can be used. 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, is a commonly used regimen 1. Alternative medications include procainamide (20-50 mg/min until arrhythmia suppression, hypotension, QRS widening, or maximum dose of 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).
Key considerations in the management of acute VTach include:
- Identifying and correcting underlying causes such as electrolyte abnormalities, ischemia, or drug toxicity
- Administering oxygen and establishing IV access
- Maintaining continuous cardiac monitoring
- Evaluating patients for long-term therapy, including antiarrhythmic medications, implantable cardioverter-defibrillators, or catheter ablation to prevent recurrence. The most recent and highest quality study, the 2015 ESC guidelines 1, provides the basis for these recommendations, prioritizing morbidity, mortality, and quality of life as the primary outcomes.
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)
To treat acute VTach, amiodarone can be used. The recommended dose is approximately 1000 mg over the first 24 hours of therapy. In cases of breakthrough episodes of VT, 150 mg supplemental infusions of amiodarone can be administered over 10 minutes. Key points to consider:
- Initial dose: 1000 mg over 24 hours
- Supplemental dose: 150 mg for breakthrough episodes
- Administration: through a central venous catheter, using a volumetric infusion pump, and with an in-line filter 2, 2
From the Research
Treatment Options for Acute VTach
- For 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 3
- Procainamide demonstrates the greatest efficacy for the treatment of stable, monomorphic VT, with a recommended maximum dose of 10 mg/kg at 50-100 mg/min intravenous (IV) over 10-20 min 4
- Amiodarone is also effective, but its use is surrounded by controversy, and it has never been studied in the setting of stable ventricular tachycardia 5
Comparison of Treatment Options
- A historical multicenter comparison study found that procainamide and amiodarone have similar effectiveness for the termination of sustained stable ventricular tachycardia, with termination rates of 30% and 25%, respectively 6
- A study on the use of amiodarone in the prehospital setting found that it was relatively safe and moderately effective, with approximately half of the patients treated with amiodarone reverting from VT while under paramedic care 7
Recommendations
- Direct current cardioversion is the most efficacious treatment for stable, monomorphic VT 4
- If medical management is chosen, procainamide is the most effective option, but its use should be monitored closely due to the risk of hypotension 4, 6
- Amiodarone may be considered as an alternative, but its effectiveness and safety should be carefully evaluated 3, 5, 7