Acute ventricular tachycardia management (hemodynamically unstable versus stable)
Hemodynamically unstable ventricular tachycardia should be treated with direct current cardioversion. [1] Hemodynamically stable ventricular tachycardia should be treated with antiarrhythmic pharmacotherapy to attempt termination. [1] A wide-QRS tachycardia with diagnostic uncertainty should be presumed to be ventricular tachycardia until proven otherwise. [1]
Hemodynamic classification and initial actions
Hemodynamic instability is an indication for immediate direct current cardioversion. [1] An ECG should be obtained for stable rhythms. [1] Wide-complex tachycardias with unclear diagnosis should be presumed to be ventricular tachycardia. [1]
Unstable patient ventricular tachycardia algorithm (with pulse)
Direct current cardioversion is recommended for patients presenting with ventricular tachycardia with hemodynamic instability (Class I, Level A). [1]
Stable patient ventricular tachycardia algorithm (with pulse)
Intravenous procainamide is recommended as useful to attempt termination of hemodynamically stable ventricular tachycardia (Class IIa, Level A). [1] Intravenous amiodarone or intravenous sotalol may be considered to attempt termination of hemodynamically stable ventricular tachycardia (Class IIb, Level B-R). [1] Intravenous lidocaine is an alternative antiarrhythmic medication of long-standing and widespread familiarity. [1] Antiarrhythmic selection is guided by clinical context and medication safety considerations, including proarrhythmic risk with QT-prolonging agents. [1]
Polymorphic ventricular tachycardia and ventricular fibrillation considerations
No randomized trials establish optimal pharmacologic management of polymorphic ventricular tachycardia. [2] Treatment of causative myocardial ischemia is recommended along with antiarrhythmic therapy and defibrillation when polymorphic ventricular tachycardia is sustained. [2] Lidocaine and amiodarone may be used in concert with defibrillation for sustained polymorphic ventricular tachycardia. [2]
Long-term prevention of recurrent ventricular tachycardia and sudden death
An implantable cardioverter-defibrillator is recommended for secondary prevention in patients who survive sudden cardiac arrest due to VT/VF or who experience hemodynamically unstable VT or stable sustained VT not due to reversible causes, provided meaningful survival greater than 1 year is expected (Class I, Level B-R or B-NR). [1] In patients with ischemic heart disease and ICD shocks for sustained monomorphic VT that is recurrent, or hemodynamically tolerated, catheter ablation as first-line therapy may be considered to reduce recurrent ventricular arrhythmias (Class IIb, Level C-LD). [1]
Long-term rhythm control options
Catheter ablation is recommended for electrical storm when antiarrhythmic medication therapy has failed or is not tolerated (Class I, Level B-R). [1] In patients with NICM and an ICD who experience spontaneous ventricular arrhythmias or recurrent appropriate shocks despite optimal device programming and beta-blocker therapy, amiodarone or sotalol can be beneficial (Class IIa, Level B-R). [1] In patients with recurrent sustained monomorphic ventricular tachycardia in NICM who fail or are intolerant of antiarrhythmic medications, catheter ablation can be useful for reducing recurrent VT and ICD shocks (Class IIa, Level B-NR). [1] For symptomatic outflow tract ventricular arrhythmias in an otherwise normal heart in whom antiarrhythmic medications are ineffective, not tolerated, or not the patient’s preference, catheter ablation is useful (Class I, Level B-NR). [1]