- •Wide complex tachycardia in patients with structural heart disease is most likely ventricular tachycardia (VT), but the 12-lead electrocardiogram should be systematically analyzed for confirmation.
- •Direct current cardioversion or infusion of intravenous amiodarone, procainamide, or lidocaine is usually successful for acutely terminating VT.
- •A combination of β-blockers and amiodarone is the most effective medical treatment for preventing recurrent VT after implantable cardioverter-defibrillator placement.
- •Catheter ablation is an effective treatment of recurrent VT despite antiarrhythmic therapy, but success rates vary depending on the mechanism and substrate of VT.
- •Electrical storm that continues despite defibrillation, β-blockade, and antiarrhythmics may respond to general anesthesia, left stellate ganglion blockade, hemodynamic support, or catheter ablation.
Epidemiology of Ventricular Arrhythmias
|Vital signs||Hemodynamic stability||If hemodynamically unstable, treat with urgent DCCV or defibrillation|
|12-lead ECG||Tachycardia diagnosis||Differentiate VT from SVT with aberrancy; determine VT exit site|
|History||Symptoms (eg, chest pain indicating ongoing ischemia)||Identify cause and triggers|
|Current medications||Antiarrhythmics, digoxin, QTc-prolonging medications||Identify pharmacologic contribution to a proarrhythmic state|
|Family history||Family history of SCD||Determine risk of inherited predisposition to SCD|
|Physical examination||Canon A waves||Indicate AV dissociation|
|Murmurs, sternotomy scar||Indicate existing structural heart disease|
|Laboratory tests||Electrolytes, creatinine, troponin, thyroid-stimulating hormone, toxicology assays||Identify metabolic, ischemic, or pharmacologic contributions to a proarrhythmic state|
|Imaging||Chest roentgenography, echocardiography||Indicated in all patients with VT to assess for structural heart disease|
|Coronary angiography||Indicated if VT occurs secondary to ischemia|
|Computed tomography, magnetic resonance imaging||Indicated in special cases when particular cardiomyopathies are suspected|
- •Absence of an RS complex in the precordial leads: 100% specific for VT
- •RS interval (beginning of R to trough of S) greater than 100 milliseconds: 98% specific for VT
- •Atrioventricular dissociation: 98% specific for VT
- •Apply morphologic criteria to V1 and V6. If both leads are consistent with VT, then VT is diagnosed; otherwise, the rhythm is classified as SVT with aberrancy.
Nonpharmacologic therapeutic modalities
External Defibrillation and Cardioversion
- Zipes D.P.
- Camm A.J.
- Borggrede M.
- et al.
- •Biphasic waveform defibrillation improves initial success of defibrillation.
- •In VT, unsynchronized DCCV can precipitate VF.
Implantable Cardioverter-Defibrillator and Pacing
- •ICD implantation significantly reduces mortality from SCD in high-risk patients.
- •Inappropriate ICD therapy can be halted by applying a magnet over the device.
Left Cardiac Sympathetic Denervation
Radiofrequency Catheter Ablation
Intravenous Medications for Acute Management
- •Procainamide is preferred for pharmacologic cardioversion of stable VT in patients with normal systolic function.
- •Lidocaine is useful for VT during acute ischemia; it does not cause QTc prolongation.
- •Amiodarone is the most effective antiarrhythmic for VT but requires time to load.
|Antiarrhythmic||Dosing||Acute Adverse Reactions|
|Procainamide||Load: 17 mg/kg|
Maximum rate: 50 mg/min
Maintenance: 1–4 mg/min
Hold if QRS prolongs >50%
|Lidocaine||Load: 1–3 mg/kg|
Rate: 20–50 mg/min
Maintenance: 1–4 mg/min
|Reduce dose in heart failure|
Monitor for neurotoxicity: delirium, seizures, or paresthesias
|Amiodarone||Load: 150 mg over 10 min if blood pressure is normal; 300 mg over 19 min if hypotensive|
Maintenance: 1 mg/min for 6 h, then 0.5 mg/min for 18 h
|Caution in cardiogenic shock|
TdP is rare
Use with pacing if patient is severely bradycardic
Long-Term Oral Therapy
- •A combination of β-blockers and amiodarone is the most successful long-term medical strategy for reducing defibrillator shocks.
- •β-blockers improve survival in patients after VT or VF is treated.
- Zipes D.P.
- Camm A.J.
- Borggrede M.
- et al.
VT in patients with structural heart disease
VT in Patients with Acute MI
- Zipes D.P.
- Camm A.J.
- Borggrede M.
- et al.
VT in Revascularized Patients with Ischemic Cardiomyopathy
- •Catheter ablation of VT before initiation of long-term antiarrhythmic therapy is reasonable in patients with sustained VT and a previous MI.
VT in Patients with Nonischemic Cardiomyopathy
- •Catheter ablation of VT in nonischemic cardiomyopathy has variable success rates depending on the mechanism and substrate of VT.
VT in Patients After Cardiac Surgery
- •Amiodarone prophylaxis reduces postoperative VT and VF.
VT in Patients with VADs
- •VT in patients with a VAD comes predominantly from the preexisting substrate rather than from the inflow cannula site.
VT in Patients After Orthotopic Heart Transplantation
- •Rejection must be ruled out in patients with orthotopic heart transplantation and VT.
VT in Patients with Congenital Heart Disease
VT in patients with structurally normal hearts
VT in Patients with Brugada Syndrome
- •In patients with Brugada syndrome presenting with VT, isoproterenol infusion should be initiated after DCCV and titrated until the ST segments normalize.
VT in Patients with TdP
- •Pacing prevents recurrent TdP while awaiting clearance of offending medications.
VT in Patients with Congenital LQTS
- •β-blockade combined with pacing prevents recurrent VT in LQTS.
VT in Patients with CPVT
VT in Patients with Idiopathic VT
- •Patients with RVOT VT should be evaluated to exclude ARVD.
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Disclosure: The authors have nothing to disclose.