How to manage Ventricular Tachycardia (VT) storm?

From the Guidelines

To manage VT storm, immediately administer intravenous amiodarone 150 mg over 10 minutes, followed by 1 mg/min for 6 hours, then 0.5 mg/min maintenance, as recommended by the most recent guidelines 1.

Management of VT Storm

The management of VT storm involves a combination of pharmacological and non-pharmacological interventions.

• For hemodynamically unstable patients, perform immediate electrical cardioversion at 100-200 joules (biphasic) or 360 joules (monophasic), as recommended by the European Society of Cardiology 1.
• Beta-blockers like metoprolol (5 mg IV every 5 minutes, up to 3 doses) should be added if not contraindicated, as they can help reduce the risk of recurrent VT 1.
• Correct underlying causes such as electrolyte abnormalities (maintain potassium >4.0 mEq/L and magnesium >2.0 mg/dL), ischemia, or heart failure, as these can trigger VT storm 1.
• Sedation with benzodiazepines may help reduce sympathetic tone and prevent recurrent VT, as suggested by the American College of Cardiology/American Heart Association Task Force 1.

Refractory Cases

For refractory cases, consider:

• General anesthesia
• Stellate ganglion blockade
• Overdrive pacing
• If medication-refractory, catheter ablation may be necessary, as recommended by the American College of Cardiology/American Heart Association Task Force 1. VT storm represents a medical emergency with multiple (≥3) sustained VT episodes within 24 hours, often triggered by acute myocardial injury, electrolyte disturbances, or medication effects. The goal is to suppress ventricular arrhythmias while addressing the underlying cause to prevent recurrence and reduce mortality risk.

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. For breakthrough episodes of VF or hemodynamically unstable VT, repeat the Initial Load. The recommended starting dose is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen: The rate of the maintenance infusion may be increased to achieve effective arrhythmia suppression In the event of breakthrough episodes of VF or hemodynamically unstable VT, use 150 mg supplemental infusions of amiodarone

To manage VT storm, 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 2.
• Administer the recommended starting dose of about 1000 mg over the first 24 hours of therapy, delivered by the specified infusion regimen 2.
• For breakthrough episodes of VF or hemodynamically unstable VT, repeat the Initial Load of 150 mg 2.
• Increase the rate of the maintenance infusion as needed to achieve effective arrhythmia suppression 2.
• Use 150 mg supplemental infusions of amiodarone for breakthrough episodes 2.

From the Research

Management of VT Storm

To manage VT storm, several strategies can be employed, including the use of antiarrhythmic drugs. The choice of drug depends on various factors, including the patient's condition, the presence of structural heart disease, and the availability of the drug.

• Antiarrhythmic Drug Therapy: Antiarrhythmic drugs such as amiodarone, lidocaine, and procainamide can be used to manage VT storm 3, 4, 5, 6, 7.
• Comparison of Antiarrhythmic Drugs: Studies have compared the efficacy of different antiarrhythmic drugs in managing VT storm. For example, a study found that procainamide was associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 minutes compared to amiodarone 5.
• Factors Influencing Drug Choice: The choice of antiarrhythmic drug may depend on factors such as the patient's condition, the presence of structural heart disease, and the availability of the drug. For example, a study found that lidocaine was associated with higher odds of return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone in patients with in-hospital cardiac arrest from VT/VF 6.
• Safe and Effective Use of Antiarrhythmic Agents: To ensure safe and effective use of antiarrhythmic agents, clinicians should be aware of the potential disadvantages and require additional monitoring during use. A review discussed indications and strategies for safe and effective use of amiodarone, lidocaine, and procainamide in the critical care setting 7.

Treatment Options

Treatment options for VT storm include:

• Amiodarone: Amiodarone can be used to manage VT storm, but its use may be associated with significant adverse effects 3, 4, 5, 6, 7.
• Lidocaine: Lidocaine can be used to manage VT storm, and its use may be associated with higher odds of return of spontaneous circulation, 24-hour survival, survival to hospital discharge, and favorable neurologic outcome compared to amiodarone 6.
• Procainamide: Procainamide can be used to manage VT storm, and its use may be associated with less major cardiac adverse events and a higher proportion of tachycardia termination within 40 minutes compared to amiodarone 5.