Do you shock ventricular tachycardia (VTach) with pulse and hypotension?

From the Guidelines

For hypotensive ventricular tachycardia (VTach) with a pulse, immediate synchronized cardioversion is recommended rather than defibrillation. This approach is supported by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias, which state that direct current cardioversion is recommended for patients presenting with sustained VT and hemodynamic instability 1. The guidelines also suggest that in patients who are hypotensive and yet conscious, immediate sedation should be given before undergoing cardioversion.

When considering the treatment of hypotensive VTach with a pulse, it is essential to prioritize the patient's hemodynamic stability and prevent further deterioration. The use of antiarrhythmic medications like amiodarone may be considered in addition to cardioversion, as they can help stabilize the rhythm. According to the 2018 American Heart Association focused update on advanced cardiovascular life support, intravenous amiodarone is available in two approved formulations, and its administration has been shown to improve survival to hospital admission in patients with shock-refractory VF/pVT 2.

Key considerations in the management of hypotensive VTach with a pulse include:

• Immediate synchronized cardioversion to restore a stable cardiac rhythm
• Sedation before cardioversion if the patient is conscious and time permits
• Administration of antiarrhythmic medications like amiodarone to help stabilize the rhythm
• Continuous cardiac monitoring after cardioversion to prevent recurrence
• Addressing underlying causes such as electrolyte abnormalities, ischemia, or drug toxicity to prevent further episodes.

The most recent and highest quality study supporting this approach is the 2015 ESC guidelines, which provide a comprehensive framework for the management of patients with ventricular arrhythmias 1.

From the Research

Treatment of Ventricular Tachycardia

• The treatment of ventricular tachycardia (VT) with pulse and hypotension is a critical issue in cardiology, and the use of antiarrhythmic drugs such as amiodarone is a common practice 3, 4, 5.
• According to the American Heart Association guidelines, amiodarone is included as a possible agent for hemodynamically stable monomorphic VT, non-QT prolonged polymorphic VT, and ventricular fibrillation (VF)/pulseless VT 4.
• The optimal antiarrhythmic drug therapy in the treatment of VF/pulseless VT cardiac arrest that is refractory to defibrillation is uncertain, but amiodarone has been shown to be effective in some cases 3, 5.

Use of Amiodarone

• Amiodarone has emerged as the leading antiarrhythmic therapy for termination and prevention of ventricular arrhythmia in different clinical settings because of its proven efficacy and safety 5.
• However, the use of amiodarone is associated with potential adverse effects, and its optimal and safe use requires careful patient surveillance 5, 6.
• The benefit of amiodarone appears to be for those patients in whom initial early CPR and defibrillation attempts fail and the antiarrhythmic drug is given early 3.

Comparison with Other Treatments

• The comparison of amiodarone with other treatments such as beta-blockers has shown that amiodarone is associated with comparable risk of recurrent ventricular tachyarrhythmias in implantable cardioverter-defibrillator recipients 7.
• However, the use of amiodarone is associated with less QRS narrowing, less LVEF improvement, and greater risk of death, transplant, or VAD in patients with sustained VTA and LBBB upgraded from conventional ICDs to CRT defibrillators 6.