Ventricular tachycardia medical therapy: Difference between revisions

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* [[Sotalol]] may decrease [[defibrillation threshold]]  and should be avoided in patients with [[LVEF]]< 20% due to decompensation of [[heart failure]].<ref name="Page2000">{{cite journal|last1=Page|first1=Richard L|title=Effects of antiarrhythmic medication on implantable cardioverter-defibrillator function|journal=The American Journal of Cardiology|volume=85|issue=12|year=2000|pages=1481–1485|issn=00029149|doi=10.1016/S0002-9149(00)00799-2}}</ref>
* [[Sotalol]] may decrease [[defibrillation threshold]]  and should be avoided in patients with [[LVEF]]< 20% due to decompensation of [[heart failure]].<ref name="Page2000">{{cite journal|last1=Page|first1=Richard L|title=Effects of antiarrhythmic medication on implantable cardioverter-defibrillator function|journal=The American Journal of Cardiology|volume=85|issue=12|year=2000|pages=1481–1485|issn=00029149|doi=10.1016/S0002-9149(00)00799-2}}</ref>


==[[ Calcium channel blocker]]==
===[[ Calcium channel blocker]]===
* [[Non-dihydropyridines calcium channel blockers]] have no role in the treatment of most [[ventricular arrhythmia]]s.
* [[Non-dihydropyridines calcium channel blockers]] have no role in the treatment of most [[ventricular arrhythmia]]s.
* In [[patients]] with prior [[MI]] administration of intravenous [[verapamil]] for sustained [[VT]] has been associated with [[hemodynamic collapse ]].<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>
* In [[patients]] with prior [[MI]] administration of intravenous [[verapamil]] for sustained [[VT]] has been associated with [[hemodynamic collapse ]].<ref name="BuxtonMarchlinski1987">{{cite journal|last1=Buxton|first1=Alfred E.|last2=Marchlinski|first2=Francis E.|last3=Doherty|first3=John U.|last4=Flores|first4=Belinda|last5=Josephson|first5=Mark E.|title=Hazards of intravenous verapamil for sustained ventricular tachycardia|journal=The American Journal of Cardiology|volume=59|issue=12|year=1987|pages=1107–1110|issn=00029149|doi=10.1016/0002-9149(87)90857-5}}</ref>

Revision as of 04:21, 19 May 2021

Ventricular tachycardia Microchapters

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Overview

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Differentiating Ventricular Tachycardia from other Disorders

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3], Avirup Guha, M.B.B.S.[4]

Overview

Medical Therapy

Common medications for treatment of VT include:[1]

Antiarrhythmic medications

[2]

Sodium channel blocker

Ranolazine

  • NO efficacy in reduction the fist VT, VF in high risk patients, but significant reduction of recurrent VT, VF requiring ICD implantation.[7]

Beta blocker

Amiodarone, sotalol

Calcium channel blocker

Electrolytes

Fatty acids, Lipids



Arrhythmiac medication, class, dose Indication Receptor target Electrophysiologic effect Pharmacological characteristics Common advers effects
Acebutolol

PO 200–1200 mg daily, up to 600 mg bid

VT, PVC B1, mild internistic sympathetic activity Slowing sinus rate, increasing AV nodal refractoriness Prolonged haft life in renal impairment, metabolism: hepatic Bradycardia, hypotension, HF, AV block, Dizziness, fatigue, anxiety, impotence, hyperesthesia,hypoesthesia
Amiodarone (III)

IV:VF/pulseless VT arrest: 300 mg bolus, stable VT: 150-mg bolus then 1 mg/min x 6 h, then 0.5 mg/min x 18 h PO: 400 mg q 8 to 12 h for 1–2 wk, then 300–400 mg daily; reduce dose to 200 mg daily if possible

VT, VF, PVC INa, ICa, IKr, IK1, IKs, Ito, Beta receptor, Alpha receptor, nuclear T3

recepto

Slowed sinus rate, QRS prolongation, QTc prolongation, increased AV nodal refractoriness ,increased defibrilation threshold Metabolism: hepatic, half life: 26-107 days Hypotension, bradycardia, AV block, TdP, slowing VT below programmed ICD detection rate, increased defibrillation threshold, corneal microdeposits, thyroid abnormalities, ataxia, nausea, emesis, constipation, photosensitivity, skin discoloration, ataxia, dizziness, peripheral neuropathy, tremor, hepatitis, cirrhosis, pulmonary fibrosis, pneumonitis
Atenolol (II)

PO: 25–100 mg qd or bid

VT, PVC, ARVC, LQTS Beta 1 Slowed sinus rate ,
increased AV nodal refractoriness
Metabolism: hepatic Bradycardia, hypotension, heart failure, AV block, dizziness, fatigue, depression, impotence
Bisoprolol (II)

PO: 2.5–10 mg once daily

VT, PVC Beta 1 receptor Slowed sinus rate, increased AV nodal refractoriness Metabolism: hepatic Chest pain, bradycardia, AV block, Fatigue, insomnia, diarrhea
Carvedilol (II)

PO: 3.125–25 mg q 12 h

VT, PVC Beta 1, Beta 2, Alpha Slowed sinus rate, increased AV nodal refractoriness Metabolism: hepatic Bradycardia, hypotension, AV block, edema, syncope, Hyperglycemia, dizziness, fatigue, diarrhea
Carvedilol (II)

PO: 3.125–25 mg q 12 h

VT, PVC Beta 1, Beta 2, Alpha Slowed sinus rate, increased AV nodal refractoriness Metabolism: hepatic Bradycardia, hypotension, AV block, edema, syncope, Hyperglycemia, dizziness, fatigue, diarrhea
Diltiazem (IV)

IV: 5–10 mg,qd: 15–30 min, Extended release: PO: 120–360 mg/da, PO: 3.125–25 mg q 12 h

RVOT VT, ideopathic left VT ICa-L Slowed sinus rate, slowed AV node conduction, PR prolongation Metabolism: hepatic Bradycardia, hypotension, AV block, edema, exacerbation of HF reduced EF, Headache, rash, constipation
Esmolol (II)

IV: 0.5 mg/kg bolus, 0.05 mg/kg/min

VT B1 Slowed sinus rate, increased AV node refractoriness Metabolism: RBC Bradycardia, hypotension, AV block, HF, dizziness, neusea
Flecainide (IC) PO: 50–200 mg q 12 h VT, PVC (in the absence of structural heart disease), CPVT INa, IKr, IKur Prolonged PR interval, prolonged QRS duration, increased defibrillation threshold Metabolism: RBC Sinus node dysfunction, AV block, drug-induced Brugada syndrome, monomorphic VT in patients with a myocardial scar, exacerbation of HFrEF
Lidocaine (IB)

IV: 1 mg/kg bolus, 1–3 mg/min, 1–1.5 mg/kg. Repeat 0.5–0.75 mg/kg bolus every 5–10 min (max cumulative dose 3 mg/kg), maintenance infusion: 1–4 mg/min or starting 0.5 mg/min

VT, VF INa Slightly shortening of QTc interval Metabolism: hepatic, prolonged half life in HF, liver disease, shock, severe renal disease Bradycardia, hemodynamic collapse, AV block, sinus arrest, delirium, psychosis, seizure, nausea, tinnitus, dyspnea, bronchospasm
Metoprolol (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h VT, PVC B1 Slowed sinus rate, increased AV nodal refractoriness Metabolism: None, Excretion: urine Bradycardia, hypotension, AV block, dizziness, fatigue, diarrhea, depression, dyspnea
Metoprolol (II) IV: 5 mg q 5 min up to 3 doses, PO: 25–100 mg Extended release qd or q 12 h VT, PVC B1 Slowed sinus rate, increased AV nodal refractoriness Metabolism: None, Excretion: urine Bradycardia, hypotension, AV block, dizziness, fatigue, diarrhea, depression, dyspnea
Mexiletine (IB), PO: 150–300 mg q 8 h or q 12 h VT, PVC, VF, Long QT3 INa Slightly shortening of QTc interval Metabolism: hepatic HF, AV block, lightheaded, tremor, ataxia, paresthesias, nausea, blood dyscrasias
Nadolol (II)

PO: 40–320 mg daily

VT, PVC, LQTS, CPVT B1, B2 Slowed sinus rate, increased AV nodal refractoriness Metabolism: none, excretion: urine Bradycardia, hypotension, HF, AV block, edema, dizziness, cold extremities, bronchospasm
Procainamide (IA), IV: loading dose 10–17 mg/kg at 20–50 mg/min, maintenance dose: 1–4 mg/min, PO (SR preparation): 500–1250 mg q 6 h VT, PVC, LQTS, CPVT B1, B2 Slowed sinus rate, increased AV nodal refractoriness Metabolism: none, excretion: urine Bradycardia, hypotension, HF, AV block, edema, dizziness, cold extremities, bronchospasm
Propafenone (IC), PO: Immediate release 150–300 mg q 8 h, Extended release 225–425 mg q 12 h VT, PVC (in the absence of structural heart disease]] INa, IKr, IKur, Beta receptor, Alpha recept Prolonged PR interval, prolonged QRS duration, increased defibrillation threshold Metabolism: hepatic HF, AV block, drug-induced Brugada syndrome, dizziness, fatigue, nausea, diarrhea, xerostomia, tremor, blurred vision
Propranolol (II), IV: 1–3 mg q 5 min to a total of 5 mg, PO: Immediate release 10–40 mg q 6 h; Extended release 60–160 mg q 12 h VT, PVC, Long QT syndrome Beta 1 , B2 , INa Slowed sinus rate, increased AV nodal refractoriness Metabolism: hepatic Bradycardia, hypotension, HF, AV block, sleep disorder, dizziness, nightmares, hyperglycemia, diarrhea, bronchospasm
Quinidine (IA), PO: sulfate salt 200–600 mg q 6 h to q 12 h, gluconate salt 324–648 mg q 8 h to q 12 h, IV: loading dose: 800 mg in 50 mL infused at 50 mg/min VT, VF, short QT syndrome, brugada INa, Ito, IKr, M, Alpha receptor QRS prolongation, QTc prolongation, increased defibrillation threshold Metabolism: hepatic [[Syncope], torsades de pointes, AV block, dizziness, diarrhea, nausea, esophagitis, emesis, tinnitus, blurred vision, rash, weakness, tremor, blood dyscrasias
Ranolazine (not classified), PO: 500–1000 mg q 12 h VT INa, IKr Slowed sinus rate, QTc prolongation Metabolism: hepatic Bradycardia, hypotension, headache, dizziness, syncope, nausea, dyspnea
Sotalol (III), IV: 75 mg q 12 h, PO: 80–120 mg q 12 h, may increase dose every 3 d; max 320 mg/d VT, VF, PVC B1, B2 IKr Slowed sinus rate, QTc prolongation, increased AV nodal refractoriness, decreased defibrillation threshold Metabolism: none Bradycardia, hypotension, HF, syncope, TdP, fatigue, dizziness, weakness, dyspnea, bronchitis, depression, nausea, diarrhea
Verapamil, IV: 2.5–5 mg q 15–30 min, sustained release PO: 240–480 mg/d RVOT VT, verapamil-sensitive idiopathic Left VT ICa-L Slowed sinus rate,PR prolongation, slowed AV nodal conduction Metabolism: hepatic Hypotension, edema, HF, AV block, bradycardia, exacerbation of HF reduced EF, headache, rash, gingival hyperplasia, constipation, dyspepsia

Specific recommendation

2017 ACC/AHA/HRS Guideline for management of ventricular tachycardia

[2]

Class I
"1. In heart failure reduced EF (LVEF< 40%) for reducing the risk of SCD and all cause mortality, use of betablocker, a mineralocontocoid receptor antagonist, and either an angiotensin converting enzyme inhibitor, an angiotensin receptor blocker, or an angiotensin receptor neprilysin inhibitor is recommended. (Level of Evidence A)"

Specific notes


 
 
 
 
 
 
 
 
 
 
Sustained monomorphic VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemodynamic stability
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12-Lead ECG, history, physical exam
 
 
 
 
 
 
 
 
 
 
 
Dirrect current cardioversion,ACLS
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notifying disease causing VT
 
 
 
Cardioversion(class1)
 
 
 
 
 
 
 
VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Structural heart disease
 
 
 
Intravenous procainamide (class2a)
 
 
 
 
 
Yes, therapy of underlying heart disease
 
NO, cardioversion (class1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO, Ideopathic VT
 
 
 
Intravenous amiodarone or sotalole (class2b)
 
 
 
 
 
 
 
 
VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Verapamil sensitive VT: Verapamil outflow tract VT: betablocker (class2a)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Effective
 
Non effective: cardioversion
 
 
 
 
 
 
 
 
Yes,therapy of underlying heart disease
 
NO, Sedation ,anesthesia, reassessing antiarrhythmic therapy, repeating cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Therapy to prevent recurrence of VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No VT termination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation (class1)
 
 
Catheter ablation (class1)
 
Verapamil , betablocker (class2a)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The above algorithm adopted from 2017 AHA/ACC/HRS Guideline

Comments





Recommendations for treatment of recurrent ventricular tachycardia in ischemic heart disease
Medications (Class I, Level of Evidence B):

❑ In patients with IHD and recurrent symptomatic ventricular tachycardia and frequent ICD shocks despite programming, betablocker, sotalol, amiodarone is recommended for supression of arrhythmia
❑ In patients with period MI and presence of VT storm refractory to amiodarone or other antiarrhythmic drugs, catheter ablation is recommended

Catheter ablation (Class IIb, Level of Evidence C) :

Catheter ablation can be the first line therapy for recurrent sustained monomorphic VT in IHD

(Class III, Level of Evidence C)

❑ Class IC antiarrhythmic drugs (flecainide, propafenone ) is harmful for supression of ventricular tachycardia in patients with perior MI
❑ In patients with incessant VT/VF, after controlling tachyarrhythmia ICD should be implanted due to avoiding of repeated ICD shocks
❑ In patients with recurrent monomorphic VT , only revascularization is ineffective for preventing of tachyarrhythmia

The above table adopted from 2017 AHA/ACC/HRS Guideline

Message

Recommendations for treatment of recurrent ventricular tachycardia in non-ischemic heart disease
Amiodarone, sotalol (Class IIa, Level of Evidence B):

Amiodarone or sotalol is recommended in the presensence of recurrent ventricular arrhythmia and frequent ICD shocks despite optimal programming or betablocker therapy

Catheter ablation (Class IIa, Level of Evidence B) :

❑ In the setting of frequent ventricular arrhythmia despite optimal ICD programming or failed antiarrhythmic medications, catheter ablation is recommended

The above table adopted from 2017 AHA/ACC/HRS Guideline

References

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