What is the treatment for ventricular tachycardia?

Treatment of Ventricular Tachycardia

For hemodynamically unstable VT (hypotension, altered mental status, chest pain, acute heart failure, or shock), perform immediate synchronized DC cardioversion at 100J, 200J, then 360J with prior sedation if the patient is conscious. 1, 2

Initial Assessment: Determine Hemodynamic Stability

The critical first step is assessing whether the patient is stable or unstable. Unstable VT is defined by the presence of any of these adverse signs: 2

• Hypotension (systolic BP ≤90 mmHg) 2
• Chest pain suggesting ongoing ischemia 2
• Acute heart failure (pulmonary edema, dyspnea) 2
• Altered mental status (inadequate cerebral perfusion) 2
• Signs of shock (cool extremities, decreased urine output) 2

If any of these are present, the patient is unstable and requires immediate cardioversion—do not delay for IV access or medications. 2

Hemodynamically Unstable VT: Immediate Cardioversion

Synchronized DC cardioversion is the definitive treatment for unstable VT. 1, 2 The approach is:

• Immediate cardioversion at escalating energy levels: 100J → 200J → 360J 1, 3, 2
• Provide sedation before cardioversion if the patient is conscious but unstable 1, 2
• Do not delay cardioversion to establish IV access or administer medications 2
• Have resuscitation equipment immediately available 2

After successful cardioversion, initiate an antiarrhythmic infusion to prevent recurrence. 3

Hemodynamically Stable VT: Pharmacological Management

For stable VT (patient alert, BP adequate, no signs of shock), pharmacological therapy is first-line. 1, 2

First-Line Antiarrhythmic Options

Amiodarone is the preferred agent for stable VT, particularly in patients with structural heart disease or heart failure: 2, 4

• Loading dose: 150 mg IV over 10 minutes 1, 3, 2
• Maintenance infusion: 1.0 mg/min for 6 hours, then 0.5 mg/min 3, 2, 4
• Combine with IV beta-blockers for optimal efficacy 3, 2
• FDA-approved for frequently recurring VF and hemodynamically unstable VT refractory to other therapy 4

Procainamide is an alternative first-line option with the greatest efficacy among medical therapies for stable monomorphic VT: 3, 2, 5

• Loading infusion: 20-30 mg/min up to maximum 10-17 mg/kg 3, 2
• Maintenance infusion: 1-4 mg/min 6
• Avoid in patients with severe heart failure or acute MI 1, 6
• FDA-approved for documented life-threatening ventricular arrhythmias including sustained VT 5

Lidocaine (lignocaine) is a second-line alternative, particularly useful when VT is ischemia-related: 3, 2

• Initial bolus: 1.0-1.5 mg/kg IV (maximum 100 mg) 3, 2
• Repeat boluses: 0.5-0.75 mg/kg every 5-10 minutes to maximum 3 mg/kg total 3, 6
• Maintenance infusion: 2-4 mg/min 3, 2
• For stable VT, the British Journal of Sports Medicine recommends 50 mg over 2 minutes, repeated every 5 minutes to total 200 mg, then 2 mg/min maintenance 3

Special Situation: Torsades de Pointes (Polymorphic VT with Long QT)

For torsades de pointes, immediately administer magnesium 8 mmol (2 grams) IV bolus, especially if hypomagnesemia is suspected. 3, 6, 2

• This is effective even without documented hypomagnesemia 3
• IV beta-blockers are the single most effective therapy for polymorphic VT storm 6, 2

VT Storm (Electrical Storm): Recurrent or Incessant VT

For VT storm, combine IV amiodarone with IV beta-blockers as first-line therapy: 6

• Amiodarone: 150 mg over 10 minutes, then 1.0 mg/min for 6 hours, then 0.5 mg/min 6
• Beta-blockers are the single most effective therapy for polymorphic VT storm 6, 2
• Consider urgent catheter ablation after initial stabilization, as it can acutely terminate electrical storm 1, 6

For refractory VT storm despite optimal medical therapy: 6

• Overdrive pacing may be considered 6
• General anesthesia may be considered 6
• Mechanical circulatory support (LV assist device, ECMO) should be considered in hemodynamically unstable patients 6

Critical Contraindications and Pitfalls

Avoid these medications entirely in VT patients: 2

• Calcium channel blockers (verapamil, diltiazem): Can precipitate ventricular fibrillation or profound hypotension, especially in patients with myocardial dysfunction 1, 2
• Adenosine: Should not be used for unstable or irregular/polymorphic wide-complex tachycardias, as it may cause degeneration to VF 2
• Class IC antiarrhythmics (flecainide, propafenone): Avoid in patients with prior MI or structural heart disease 6, 2

Important administration considerations: 3, 2

• Always follow IV drugs with a 20 mL saline bolus to aid central circulation delivery 3, 2
• Correct electrolyte abnormalities (potassium >4.0 mEq/L, magnesium >2.0 mg/dL) before and during therapy 2
• Monitor continuously for hypotension, bradycardia, and AV block during antiarrhythmic administration 2
• Have cardioversion equipment immediately available when administering any antiarrhythmic 2

Special VT Subtypes Requiring Different Approaches

For LV fascicular VT (RBBB morphology with left axis deviation): 1

• IV verapamil or beta-blockers are the treatments of choice 1
• This is one of the rare situations where verapamil is appropriate for wide-complex tachycardia 1

For right ventricular outflow tract VT, bundle-branch reentry VT, or verapamil-sensitive left ventricular VT: 1

• Catheter ablation is the appropriate first-choice treatment 1

Long-Term Management and Catheter Ablation

Urgent catheter ablation is recommended in patients with scar-related heart disease presenting with incessant VT or electrical storm. 1

Catheter ablation is recommended in patients with ischemic heart disease and recurrent ICD shocks due to sustained VT. 1

Catheter ablation should be considered after a first episode of sustained VT in patients with ischemic heart disease and an ICD. 1