How to manage ventricular tachycardia (VTach)?

From the Guidelines

Management of ventricular tachycardia (VTach) requires immediate assessment of the patient's hemodynamic stability, and for unstable patients, direct cardioversion is recommended, as stated in the 2015 ESC guidelines 1. For unstable patients with pulseless VTach, immediate defibrillation at 200J biphasic (or 360J monophasic) followed by CPR is crucial.

• Key considerations in managing VTach include:
  • Assessing hemodynamic stability
  • Correcting underlying causes such as electrolyte abnormalities, ischemia, or drug toxicity
  • Administering antiarrhythmic medications for hemodynamically stable patients
• For hemodynamically stable VTach, intravenous procainamide or flecainide may be considered for those who do not present with severe HF or acute myocardial infarction, while intravenous amiodarone may be considered in patients with HF or suspected ischemia, as per the 2015 ESC guidelines 1.
• The 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations also suggests that procainamide is recommended for patients with hemodynamically stable monomorphic ventricular tachycardia (mVT) who do not have severe congestive heart failure or acute myocardial infarction, and amiodarone is recommended for patients with hemodynamically stable mVT with or without either severe congestive heart failure or acute myocardial infarction 2.
• Long-term management includes beta-blockers, antiarrhythmics, and addressing structural heart disease, with consideration of implantable cardioverter-defibrillator placement for recurrent VTach, as these interventions can significantly impact morbidity, mortality, and quality of life.
• It is essential to prioritize the most recent and highest quality study, which in this case is the 2015 ESC guidelines 1, to guide management decisions and optimize patient outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Amiodarone hydrochloride injection is indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy. The recommended starting dose of amiodarone is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone (mixed in 100 mL of D5W and infused over 10 minutes to minimize the potential for hypotension)

To manage VTach, the following steps can be taken:

• Use amiodarone (IV) as indicated for initiation of treatment and prophylaxis of frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy 3.
• Administer a starting dose of about 1000 mg over the first 24 hours of therapy, using a recommended infusion regimen 4.
• In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone 4.
• Alternatively, procainamide (IV) can be considered, with therapeutic plasma levels ranging from 3 to 10 mcg/mL, although certain patients may require higher levels for adequate control 5.

From the Research

Management of Ventricular Tachycardia (VT)

The management of VT involves several strategies, including:

• Immediate termination of VT if the patient is hemodynamically unstable, and early termination after initial diagnostic work-up if tolerated 6
• Electrical cardioversion, anti-tachycardia pacing (if available, in cases with an implanted defibrillator [ICD]), or defibrillation to terminate VT 6
• Antiarrhythmic drug treatment to lead to rhythm stabilization in cases of VT recurrence 6
• Scrutinizing the electrocardiogram (ECG) of VT to differentiate potential mechanisms, underlying cardiac pathologies, and identify treatment options 6

Classification of VT

VT can be classified into:

• Monomorphic versus polymorphic ventricular tachycardia (VT)/ventricular fibrillation (VF) based on ECG morphology 6
• Structural VA should be differentiated from idiopathic and non-structural (idiopathic) VA 6

Treatment Options

Treatment options for VT include:

• Antiarrhythmic drugs (AADs) such as amiodarone and lidocaine 7, 8
• Catheter ablation (CA) to prevent recurrent VT in patients with ICDs 7, 9
• Concomitant amiodarone therapy may affect procedural outcomes of catheter ablation 9

Comparative Effectiveness of Treatment Options

Comparative effectiveness of treatment options for VT includes:

• Both CA and AADs reduce the risk of recurrent VT compared to control medical therapy, with no significant difference between the two treatments 7
• Lidocaine therapy was associated with statistically significantly higher rates of return of spontaneous circulation (ROSC), 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone 8
• Concomitant amiodarone therapy may be associated with higher VT recurrence at long-term follow-up after catheter ablation 9