What is the treatment for ventricular tachycardia (V-tach) as per American Heart Association (AHA) guidelines?

Treatment of Ventricular Tachycardia per AHA Guidelines

For hemodynamically unstable VTach, perform immediate synchronized cardioversion; for stable monomorphic VTach, procainamide is the preferred antiarrhythmic agent, though amiodarone is favored in patients with heart failure or ischemia. 1, 2, 3

Hemodynamically Unstable VTach

Immediate synchronized direct current cardioversion is the definitive treatment for patients presenting with hypotension, altered mental status, or signs of shock. 1

• If the patient is hypotensive but conscious, administer sedation immediately before cardioversion 1
• Use 100 J synchronized discharge for monomorphic VT with rates >150 bpm 1
• Use unsynchronized 200 J discharge for polymorphic VT that resembles ventricular fibrillation 1
• If VTach recurs after cardioversion, initiate antiarrhythmic drug therapy to prevent acute reinitiation 1

Hemodynamically Stable Monomorphic VTach

Diagnostic Confirmation

• Confirm VTach diagnosis using ECG criteria: QRS >0.14s with RBBB pattern or >0.16s with LBBB pattern, AV dissociation, and fusion beats 1
• When in doubt about wide-complex tachycardia, treat as VTach rather than assuming supraventricular origin 1

Pharmacological Management

Procainamide is the most efficacious first-line agent for stable monomorphic VTach: 3

• Administer 10 mg/kg IV at 50-100 mg/min over 10-20 minutes 3
• Monitor blood pressure and ECG continuously during infusion 3
• Procainamide is FDA-indicated for documented life-threatening ventricular arrhythmias including sustained VTach 4

Amiodarone is preferred in specific clinical contexts: 1, 2

• Use in patients with heart failure or suspected myocardial ischemia 1
• FDA-approved for frequently recurring VF and hemodynamically unstable VTach refractory to other therapy 2
• Can be safely administered for 48-96 hours or longer if necessary 2

When Pharmacological Therapy Fails

• Proceed to synchronized cardioversion if antiarrhythmic drugs are ineffective or contraindicated 1
• Do not administer multiple sequential antiarrhythmic agents if the first fails—cardiovert instead 5

Critical Warnings and Pitfalls

Avoid calcium channel blockers (verapamil, diltiazem) in VTach with structural heart disease—they may precipitate hemodynamic collapse and worsen outcomes. 1

• Only use calcium channel blockers if you are certain the rhythm is fascicular VT 1
• This is a common and potentially fatal error in wide-complex tachycardia management 1

Special Populations and Timing Considerations

• Most post-MI VTach and VF occur within the first 48 hours 1
• Sustained VTach or VF occurring outside this 48-hour window requires careful evaluation, including consideration of electrophysiology studies 1
• In patients with acute myocardial infarction, hemodynamic instability and death occur significantly more often 6

Advanced Management Considerations

Catheter ablation should be considered in specific scenarios: 1

• Urgent ablation for patients with scar-related heart disease presenting with incessant VT or electrical storm 1
• After first episode of sustained VT in patients with ischemic heart disease and an ICD 1
• For recurrent ICD shocks due to sustained VT in ischemic heart disease 1

Practical Emergency Department Approach

• Direct current cardioversion remains the most efficacious treatment overall 3
• Approximately 77% of VTach patients present hemodynamically stable, allowing time for pharmacological intervention 6
• However, 51% ultimately require electrical therapy for definitive termination 6
• Therefore, ensure direct current cardioversion capability is immediately available even when attempting pharmacological management 6