Immediate Synchronized Cardioversion
This patient requires immediate synchronized cardioversion without delay. 1 The combination of hypotension (BP 72/44), tachycardia (HR 165), and symptoms (palpitations, fatigue, dyspnea) represents hemodynamically unstable tachycardia requiring emergent electrical therapy.
Why Cardioversion is the Answer
The American Heart Association explicitly recommends immediate cardioversion (Class I, Level B) for tachycardic patients who are unstable with severe signs and symptoms related to a suspected arrhythmia, including hypotension or other signs of shock. 1 This patient's systolic blood pressure of 72 mmHg with a heart rate of 165 bpm meets the definition of hemodynamic instability requiring immediate intervention. 1
The European Society of Cardiology guidelines similarly state that patients presenting with sustained ventricular tachycardia and hemodynamic instability should undergo direct cardioversion. 1 While the ECG is not shown, the clinical presentation with severe hypotension makes the rhythm etiology less relevant—immediate cardioversion is indicated regardless of whether this is VT or SVT with aberrancy. 1
Why Other Options Are Incorrect
Adenosine (Option A)
While adenosine can be considered for regular narrow-complex SVT in select unstable cases (Class IIb, LOE C), this is only reasonable when the patient is not hypotensive. 1 With a systolic BP of 72 mmHg, this patient is profoundly hypotensive and requires immediate cardioversion rather than a trial of adenosine. 1 Additionally, adenosine should never be given for irregular or polymorphic wide-complex tachycardias as it may cause degeneration to ventricular fibrillation. 1
Amiodarone (Option B)
Amiodarone's antiarrhythmic effect may take up to 30 minutes to manifest. 1 This delay is unacceptable in a hemodynamically unstable patient who requires immediate rhythm conversion. 1 While amiodarone is indicated for hemodynamically unstable VT, 2 it is used for prophylaxis and stabilization after initial electrical cardioversion, not as first-line therapy in unstable patients. 1
Beta-blocker (Option C)
Beta-blockers are contraindicated in this setting due to their negative inotropic effects, which would further compromise cardiac output in an already hypotensive patient. 1 They have no role in the acute management of hemodynamically unstable tachycardia.
Procedural Approach
Sedate the patient immediately if conscious, but do not delay cardioversion if the patient is extremely unstable. 1 Given the profound hypotension, sedation should be brief and cardioversion performed emergently.
Use synchronized cardioversion to avoid shock delivery during the relative refractory period, which could induce ventricular fibrillation. 1
Do not delay cardioversion to obtain a 12-lead ECG. 1, 3, 4 While a 12-lead ECG is helpful for rhythm diagnosis in stable patients, it should never delay immediate cardioversion in unstable patients.
For wide-complex tachycardia in an unstable patient, presume ventricular tachycardia and cardiovert immediately. 4
Post-Cardioversion Management
After successful cardioversion, establish IV access if not already done, obtain a 12-lead ECG, and consider antiarrhythmic prophylaxis with amiodarone to prevent recurrence. 1 Even if the arrhythmia self-terminates, urgent cardiology consultation is required as this represents a potentially life-threatening condition. 3, 4
Answer: D. Cardioversion