Immediate Management of Ventricular Tachycardia
For hemodynamically unstable ventricular tachycardia, perform immediate synchronized direct current cardioversion without delay; for stable patients, either electrical cardioversion or intravenous antiarrhythmic therapy (preferably amiodarone or procainamide) are appropriate first-line options. 1, 2
Initial Assessment
Rapidly determine hemodynamic stability by assessing for:
- Hypotension or signs of shock 1, 2
- Altered mental status 3, 2
- Acute chest pain or ischemic discomfort 3, 2
- Acute heart failure 3, 2
- Syncope 1
Obtain a 12-lead ECG in stable patients to confirm the diagnosis and characterize the VT morphology, but do not delay cardioversion in unstable patients. 1, 2
Establish IV access and attach continuous cardiac monitoring. 3
Management Algorithm Based on Hemodynamic Status
Hemodynamically Unstable VT
Perform immediate synchronized cardioversion starting with maximum output (or 100 J for monomorphic VT with rates >150 bpm). 1, 2, 4
- If the patient is conscious but unstable, provide immediate sedation before cardioversion 1, 2, 4
- Do not delay cardioversion while attempting pharmacological conversion 1, 2
- If a defibrillator is unavailable, attempt a precordial thump 3, 2
Hemodynamically Stable VT
You have two evidence-based options:
Option 1: Electrical cardioversion remains first-line even in stable patients 1
Option 2: Pharmacological therapy with the following hierarchy:
Intravenous amiodarone is preferred for patients with heart failure, suspected ischemia, or structural heart disease 3, 1, 4, 5
Intravenous procainamide demonstrates the greatest efficacy among antiarrhythmics 6
Beta-blockers are first-line therapy unless contraindicated, particularly in the setting of acute myocardial infarction 3
Intravenous lidocaine is only moderately effective and considered second-line 3, 1
Special Considerations
Distinguish VT from accelerated idioventricular rhythm (ventricular rate <120 bpm), which is usually a harmless consequence of reperfusion and does not require treatment. 3, 2
For LV fascicular VT (characterized by RBBB morphology with left axis deviation), consider intravenous verapamil or beta-blockers. 1, 2
Non-sustained VT (short runs) may be well tolerated and does not necessarily require treatment if asymptomatic. 3, 2
For recurrent VT after cardioversion, administer supplemental amiodarone 150 mg IV over 10 minutes to prevent reinitiation. 4, 5
Post-Conversion Management
Monitor continuously for VT recurrence. 1, 2
Evaluate and correct underlying causes:
- Ongoing myocardial ischemia 3, 2
- Electrolyte abnormalities (particularly hypokalemia) 3, 2
- Hypoxia 3, 2
- Acid-base disturbances 3, 2
Consider catheter ablation for:
- Ischemic heart disease with recurrent VT 1
- Scar-related heart disease with incessant VT or electrical storm (urgent ablation recommended) 1, 4
- First episode of sustained VT in patients with ischemic heart disease and an ICD 4
Critical Pitfalls to Avoid
Never delay cardioversion in unstable patients while attempting pharmacological conversion—this is the most dangerous error. 1, 2
Avoid calcium channel blockers (verapamil/diltiazem) in patients with VT and suspected structural heart disease, as they may precipitate hemodynamic collapse. 1, 4
Do not use adenosine for irregular or polymorphic wide-complex tachycardias. 2
When in doubt about the diagnosis (VT versus SVT with aberrancy), treat as VT—assuming supraventricular origin can be fatal. 4
Avoid prophylactic antiarrhythmic drugs other than beta-blockers, as they may be harmful. 2