What is the algorithm to treat Ventricular Tachycardia (VT) storm?

From the Guidelines

The algorithm for treating ventricular tachycardia (VT) storm begins with immediate stabilization of the patient, prioritizing direct current cardioversion for patients presenting with sustained VT and haemodynamic instability, as recommended by the 2015 ESC guidelines 1. For hemodynamically unstable patients, perform electrical cardioversion with 100-200J biphasic shock.

• Key considerations include:
  • Administering IV amiodarone 150mg over 10 minutes, followed by 1mg/min infusion for 6 hours, then 0.5mg/min for 18 hours, for stable patients.
  • Giving beta-blockers like metoprolol (5mg IV every 5 minutes, up to 3 doses) concurrently unless contraindicated.
  • Considering IV lidocaine (1-1.5mg/kg bolus, then 1-4mg/min infusion) or procainamide (10-15mg/kg at 20-50mg/min) if VT persists.
  • Correcting any electrolyte abnormalities, particularly maintaining potassium >4.0 mEq/L and magnesium >2.0 mg/dL.
  • Using sedation to reduce sympathetic tone if necessary.
• For refractory cases, general anesthesia and mechanical ventilation might be required, followed by catheter ablation, which has been shown to decrease the likelihood of subsequent ICD shocks and prevent recurrent episodes of VT in patients with scar-related heart disease 1. VT storm is often triggered by acute myocardial ischemia, heart failure exacerbation, or electrolyte disturbances, so identifying and treating the underlying cause is essential for long-term management, with patients being monitored in an ICU setting with continuous cardiac monitoring and immediate access to defibrillation, as supported by guidelines from the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines 1.

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

The algorithm to treat VT storm involves:

• Initiating treatment with amiodarone hydrochloride injection for frequently recurring ventricular fibrillation (VF) and hemodynamically unstable ventricular tachycardia (VT) in patients refractory to other therapy 2
• Administering a starting dose of about 1000 mg over the first 24 hours of therapy 2
• Using supplemental infusions of 150 mg amiodarone in the event of breakthrough episodes of VF or hemodynamically unstable VT 2 Key points:
• Amiodarone is indicated for initiation of treatment and prophylaxis of VT and VF
• The recommended starting dose is about 1000 mg over the first 24 hours
• Supplemental infusions of 150 mg amiodarone may be used for breakthrough episodes of VT or VF The treatment should be individualized for each patient, and the dose may be adjusted based on the patient's response to the therapy 2

From the Research

Algorithm to Treat VT Storm

The treatment of ventricular tachycardia (VT) storm involves a combination of pharmacological and non-pharmacological interventions. The following steps can be taken to manage VT storm:

• Sedation and antiarrhythmic drugs to reduce the frequency and severity of VT episodes 3
• Correction of precipitating factors such as myocardial ischemia, acute decompensation of heart failure, metabolic and electrolyte disorders, drug side-effects, and increased sympathetic tone 3
• Radiofrequency catheter ablation to suppress VT episodes and achieve long-term freedom from VT 3
• Optimization of implantable cardioverter-defibrillator (ICD) programming to reduce the burden of appropriate and inappropriate shocks 3

Pharmacological Treatment

Several pharmacological agents can be used to treat VT storm, including:

• Amiodarone, which has been shown to be effective in terminating and preventing VT episodes 4, 5
• Beta-blockers, which can be used in combination with amiodarone to reduce the frequency and severity of VT episodes 5, 6
• Mexiletine, which can be used in patients with refractory VT and contraindication or inefficacy to amiodarone and beta-blockers 7

Non-Pharmacological Treatment

Non-pharmacological interventions can also be used to manage VT storm, including:

• Intubation and mechanical ventilation in severe cases 3
• Circulatory support, such as intra-aortic balloon pump or extracorporeal membrane oxygenation, in patients with severe heart failure or cardiogenic shock 3
• Deactivation of ICD therapy in patients with end-stage heart failure and refractory VT storm 3