Acute management of ventricular tachycardia
For hemodynamically unstable ventricular tachycardia (VT), intravenous amiodarone is recommended after cardioversion/defibrillation to achieve a stable rhythm (Class I, Level A). [1] For hemodynamically stable VT, intravenous procainamide can be useful to attempt to terminate VT (Class IIa, Level B-R). [1]
Medication selection algorithm
- Hemodynamically unstable VT: intravenous amiodarone after direct current cardioversion to achieve a stable rhythm (Class I, Level A). [1]
- Hemodynamically stable VT: intravenous procainamide to attempt VT termination (Class IIa, Level B-R). [1]
- Hemodynamically stable VT: intravenous amiodarone or sotalol may be considered to attempt VT termination (Class IIb, Level B-R). [1]
Key evidence supporting this recommendation
- The 2017 AHA/ACC/HRS guideline supports intravenous amiodarone for persistent or recurrent hemodynamically unstable VT after a maximal energy shock to restore a stable rhythm after further defibrillation (Class I, Level A). [1]
Monotherapy vs combination therapy
- Acute hemodynamically unstable VT should receive electrical therapy first (direct current cardioversion). [1]
- Intravenous amiodarone is used as adjunct pharmacotherapy after further defibrillation or in the setting of persistent or recurrent unstable VT. [1]
Important clarifications
- VT with hemodynamic instability should undergo direct current cardioversion rather than relying on antiarrhythmic medication alone. [1]
- VT type and stability determine medication choice, including separate pathways for hemodynamically stable versus unstable VT. [1]
Initiation thresholds
- Intravenous amiodarone should be administered for hemodynamically unstable VT that persists or recurs after a maximal energy shock to attempt to achieve a stable rhythm after further defibrillation (Class I, Level A). [1]
- Intravenous procainamide is appropriate for hemodynamically stable VT to attempt to terminate VT (Class IIa, Level B-R). [1]
Common pitfalls to avoid
- Delay of direct current cardioversion in hemodynamically unstable VT should be avoided. [1]
- Use of antiarrhythmics as the sole immediate therapy in unstable VT should be avoided. [1]
Treatment goals
- The immediate treatment goal in unstable VT is restoration of a stable rhythm after defibrillation/cardioversion with adjunct intravenous amiodarone (Class I, Level A). [1]
- The immediate treatment goal in stable VT is attempted pharmacologic termination with intravenous procainamide (Class IIa, Level B-R). [1]