Acute management of sustained ventricular tachycardia

Neumar, 2010

Ventricular tachycardia can either be nonsustained or sustained, with or without the presence of structural heart disease.

See Initial management of any acute tachyarrhythmia for initial management of any acute tachyarrhythmia and Management of stable acute wide-complex tachyarrhythmia for management of stable acute wide-complex tachyarrhythmia.

Note: Sustained ventricular tachycardia can cause sufficient haemodynamic compromise and trigger cardiac arrest—arrange urgent transfer to an emergency department via an ambulance.

Sustained ventricular tachycardia lasts for more than 30 seconds but can continue for minutes or even hours. It can present with palpitations or the consequences of reduced cardiac output, including chest pain, dyspnoea, presyncope or syncope. It can cause sufficient haemodynamic compromise and trigger cardiac arrest—arrange urgent transfer to an emergency department via an ambulance. The prognosis depends on the presence of underlying structural heart disease and left ventricular dysfunction.

For haemodynamically unstable patients with sustained ventricular tachycardia, perform DC cardioversion as soon as possiblePedersen, 2014.

Note: Perform DC cardioversion as soon as possible for haemodynamically unstable patients with sustained ventricular tachycardia.

For all patients with sustained ventricular tachycardia, consider DC cardioversion at an early stage.

For haemodynamically stable patients with sustained ventricular tachycardia, antiarrhythmic drug therapy is an option. Consult a local protocol for dosages; if a local protocol is unavailable, suitable regimens are:

1amiodarone 300 mg by intravenous infusion, over 30 minutes, followed by 900 mg by intravenous infusion over 24 hours, if requiredAl-Khatib, 2018 amiodarone amiodarone amiodarone

OR

2lidocaine 1 mg/kg (usually 75 to 100 mg) intravenously, over 1 to 2 minutes, followed, if effective, by 4 mg/minute by intravenous infusion for 1 hour, then reduce to 1 to 3 mg/minute. lidocaine lidocaine lidocaine

A lower dose of intravenous amiodarone (eg 150 mg) may be required for some patients (eg older, underweight).

If intravenous amiodarone or lidocaine are effective, sinus rhythm may be maintained by continuing therapy, or by changing to oral amiodarone or sotalol—seek specialist cardiology advice to determine ongoing treatment.

If acute drug therapy is ineffective, perform DC cardioversion.