What is the management of non-sustained ventricular tachycardia (VTach)?

From the Guidelines

The management of non-sustained ventricular tachycardia (NSVT) should prioritize the evaluation for implantable cardioverter-defibrillator (ICD) placement for primary prevention of sudden cardiac death in patients with significant structural heart disease, particularly those with prior myocardial infarction and ejection fraction ≤35%. This approach is supported by the most recent and highest quality study, which demonstrated a statistically significant 31% reduction in all-cause mortality for ICD relative to medical therapy in patients with non-ischaemic dilated cardiomyopathy 1. The following key points should be considered in the management of NSVT:

• For asymptomatic patients with structurally normal hearts, no specific treatment is typically needed beyond addressing modifiable risk factors such as electrolyte abnormalities, medication side effects, and stimulant use.
• In patients with structural heart disease, particularly those with reduced ejection fraction (≤35%), beta-blockers like metoprolol or carvedilol are first-line therapy to reduce arrhythmia burden and mortality risk.
• For symptomatic patients, amiodarone may be used, though with caution due to potential toxicities.
• Catheter ablation may be considered for recurrent symptomatic episodes or frequent PVCs triggering NSVT. It is essential to address the underlying cardiac condition, as structural heart disease creates the substrate for these arrhythmias, and the underlying mechanism of NSVT involves abnormal automaticity, triggered activity, or reentry circuits. The use of ICD therapy is recommended for primary prevention to reduce total mortality by a reduction in SCD in patients with nonischemic heart disease who have an LVEF less than or equal to 30% to 35%, are NYHA functional class II or III, are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y 1. Overall, the management of NSVT should focus on reducing the risk of sudden cardiac death and improving quality of life, while also addressing the underlying cardiac condition and symptoms.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Non-Sustained VTach

The management of non-sustained ventricular tachycardia (NSVT) depends on the underlying heart condition and symptoms.

• In patients with normal hearts, NSVT usually has a benign prognosis, and treatment is targeted toward symptoms, which may consist of:
  • Observation
  • Medical therapy
  • Catheter ablation 2
• For patients with structural or inherited heart disease, the approach is more complex and may involve:
  • Identification of high-risk patients using diagnostic tools such as determination of left ventricular function and programmed ventricular stimulation (PVS) 3
  • Treatment with beta-blockers to control symptoms 3
  • Referral for enrollment in randomized controlled studies for asymptomatic potentially high-risk patients 3
• In patients with coronary artery disease, NSVT is associated with an increased risk of sudden and nonsudden cardiac death, and treatment may involve:
  • Implantable cardioverter defibrillator (ICD) therapy for patients with sustained VT and aborted sudden cardiac death (SCD) 4
  • Beta adrenoceptor blockers to improve survival in post-myocardial infarction patients and patients with cardiomyopathy and congestive heart failure (CHF) 4
• For symptomatic NSVT, the pharmacological approach may involve:
  • Treatment with medications to control symptoms such as palpitations, near-syncope, and dizziness 5
  • Identification of underlying causes such as electrolyte imbalances and congenital heart disorders 5
• In some cases, electrophysiological study and ablation of the arrhythmia may be necessary to resolve symptoms, as seen in a patient with non-ischemic cardiomyopathy and dual chamber implantable cardioverter defibrillator 6