Ventricular tachycardia medical therapy

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

Overview

Certain antiarrhythmics such as amiodarone, vasopressin and epinephrine may be used in addition to defibrillation in the setting of VT. Long-term anti-arrhythmic therapy may be indicated to prevent the recurrence of VT.

Medical Therapy

Arrhythmiac medication, class, dose	Indication	Receotor target	Electrophysiologic effect	Pharmacological characteristics	Common advers effect
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
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Antiarrhythmic Drug Therapy

• Drugs such as amiodarone, epinephrine and vasopressin may be used in addition to defibrillation to terminate VT while the underlying cause of the VT can be determined.
• Possible causes or contributing factors to VT can be remembered as the six H's and five T's: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo- or hyperglycemia, hypothermia; and toxins, tamponade (cardiac), tension pneumothorax, thrombosis, trauma.
• Long term anti-arrhythmic therapy may be indicated to prevent recurrence of VT.
• Beta-blockers and a number of class III anti-arrhythmics are commonly used. For some of the rare congenital syndromes of VT, other drugs, and sometimes even catheter ablation therapy may be useful.
• The implantation of an ICD is more effective than drug therapy for prevention of sudden cardiac death due to VT and VF, but may be constrained by cost issues, and well as patient comorbidities and patient preference.

Contraindicated medications

Ventricular tachycardia is considered an absolute contraindication to the use of the following medications:

• Diltiazem
• Phenylephrine
• Verapamil

2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)

Management of Cardiac Arrest (DO NOT EDIT)

Class I

"1. After establishing the presence of definite, suspected, or impending cardiac arrest, the first priority should be activation of a response team capable of identifying the specific mechanism and carrying out prompt intervention. (Level of Evidence: B) "

"2. Cardiopulmonary resuscitation (CPR) should be implemented immediately after contacting a response team. (Level of Evidence: A) "

"3. In an out-of-hospital setting, if an AED is available, it should be applied immediately and shock therapy administered according to the algorithms contained in the documents on CPR developed by the AHA in association with the International Liaison Committee on Resuscitation (ILCOR) and/or the European Resuscitation Council (ERC). (Level of Evidence: C) "

"4. For victims with ventricular tachyarrhythmic mechanisms of cardiac arrest, when recurrences occur after a maximally defibrillating shock (generally 360 J for monophasic defibrillators), intravenous amiodarone should be the preferred antiarrhythmic drug for attempting a stable rhythm after further defibrillations. (Level of Evidence: B) "

"5. For recurrent ventricular tachyarrhythmias or non-tachyarrhythmic mechanisms of cardiac arrest, it is recommended to follow the algorithms contained in the documents on CPR developed by the AHA in association with ILCOR and/or the ERC. (Level of Evidence: C) "

"6. Reversible causes and factors contributing to cardiac arrest should be managed during advanced life support, including management of hypoxia, electrolyte disturbances, mechanical factors, and volume depletion. (Level of Evidence: C) "

Class IIa

" 1. For response times greater than or equal to 5 min, a brief (less than 90 to 180 s) period of CPR is reasonable prior to attempting defibrillation. (Level of Evidence: B ) "

Class IIb

" 1. A single precordial thump may be considered by health care professional providers when responding to a witnessed cardiac arrest. (Level of Evidence: C) "

Ventricular Tachycardia Associated With Low Troponin Myocardial Infarction (DO NOT EDIT)

Class I

"1. Patients presenting with sustained VT in whom low level elevations in cardiac biomarkers of myocyte injury/necrosis are documented should be treated similarly to patients who have sustained VT and in whom no biomarker rise is documented. (Level of Evidence: C)"

Sustained Monomorphic Ventricular Tachycardia (DO NOT EDIT)

Class I

"1. Wide QRS tachycardia should be presumed to be VT if the diagnosis is unclear. (Level of Evidence: C) "

"2. Direct current cardioversion with appropriate sedation is recommended at any point in the treatment cascade in patients with suspected sustained monomorphic VT with hemodynamic compromise. (Level of Evidence: C) "

Class III

"1. Calcium channel blockers such as verapamil and diltiazem should not be used in patients to terminate wide QRS complex tachycardia of unknown origin, especially in patients with a history of myocardial dysfunction. (Level of Evidence: C) "

Class IIa

" 1. Intravenous procainamide (or ajmaline in some European countries) is reasonable for initial treatment of patients with stable sustained monomorphic VT. (Level of Evidence: B) "

" 2. Intravenous amiodarone is reasonable in patients with sustained monomorphic VT that is hemodynamically unstable, refractory to conversion with countershock, or recurrent despite procainamide or other agents. (Level of Evidence: C) "

" 3. Transvenous catheter pace termination can be useful to treat patients with sustained monomorphic VT that is refractory to cardioversion or is frequently recurrent despite antiarrhythmic medication. (Level of Evidence: C) "

Class IIb

" 1. Intravenous lidocaine might be reasonable for the initial treatment of patients with stable sustained monomorphic VT specifically associated with acute myocardial ischemia or infarction. (Level of Evidence: C)"

Repetitive Monomorphic Ventricular Tachycardia (DO NOT EDIT)

Class IIa

"1.Intravenous amiodarone, beta blockers, and intravenous procainamide (or sotalol or ajmaline in Europe) can be useful for treating repetitive monomorphic VT in the context of coronary disease and idiopathic VT. (Level of Evidence: C)"

Polymorphic Ventricular Tachycardia (DO NOT EDIT)

Class I

"1. Direct current cardioversion with appropriate sedation as necessary is recommended for patients with sustained polymorphic VT with hemodynamic compromise and is reasonable at any point in the treatment cascade. (Level of Evidence: B) "

"2. Intravenous beta blockers are useful for patients with recurrent polymorphic VT, especially if ischemia is suspected or cannot be excluded. (Level of Evidence: B) "

"3. Intravenous loading with amiodarone is useful for patients with recurrent polymorphic VT in the absence of abnormal repolarization related to congenital or acquired LQTS. (Level of Evidence: C) "

"4. Urgent angiography with a view to revascularization should be considered for patients with polymorphic VT when myocardial ischemia cannot be excluded. (Level of Evidence: C) "

Class IIb

" 1. Intravenous lidocaine may be reasonable for treatment of polymorphic VT specifically associated with acute myocardial ischemia or infarction. (Level of Evidence: C)"

Torsades de Pointes (DO NOT EDIT)

Class I

"1.Withdrawal of any offending drugs and correction of electrolyte abnormalities are recommended in patients presenting with torsades de pointes. (Level of Evidence: A) "

"2. Acute and long-term pacing is recommended for patients presenting with torsades de pointes due to heart block and symptomatic bradycardia. (Level of Evidence: A)"

Class IIa

"1. Management with intravenous magnesium sulfate is reasonable for patients who present with LQTS and few episodes of torsades de pointes. Magnesium is not likely to be effective in patients with a normal QT interval. (Level of Evidence: B)"

"2. Acute and long-term pacing is reasonable for patients who present with recurrent pause-dependent torsades de pointes. (Level of Evidence: B)"

"3. Beta blockade combined with pacing is reasonable acute therapy for patients who present with torsades de pointes and sinus bradycardia. (Level of Evidence: C)"

"4. Isoproterenol is reasonable as temporary treatment in acute patients who present with recurrent pause-dependent torsades de pointes who do not have congenital LQTS. (Level of Evidence: B)"

Class IIb

"1. Potassium repletion to 4.5 to 5 mM/L may be considered for patients who present with torsades de pointes. (Level of Evidence: B)"

"2. Intravenous lidocaine or oral mexiletine may be considered in patients who present LQT3 and torsades de pointes. (Level of Evidence: C)"

Incessant Ventricular Tachycardia (DO NOT EDIT)

Class I

" 1. Revascularization and beta blockade followed by intravenous antiarrythmic drugs such as procainamide or amiodarone are recommended for patients with recurrent or incessant polymorphic VT due to acute myocardial ischemia. (Level of Evidence: C) "

Class IIa

" 1. Intravenous amiodarone or procainamide followed by VT ablation can be effective in the management of patients with frequently recurring or incessant monomorphic VT. (Level of Evidence: B)"

Class IIb

" 1. Intravenous amiodarone and intravenous beta blockers separately or together may be reasonable in patients with VT storm. (Level of Evidence: C)"

" 2. Overdrive pacing or general anesthesia may be considered for patients with frequently recurring or incessant VT. (Level of Evidence: C)"

" 3. Spinal cord modulation may be considered for some patients with frequently recurring or incessant VT. (Level of Evidence: C)"

Idiopathic Ventricular Tachycardia (DO NOT EDIT)

Class I

"1. Catheter ablation is useful in patients with structurally normal hearts with symptomatic, drug-refractory VT arising from the RV or LV or in those who are drug intolerant or who do not desire long-term drug therapy. (Level of Evidence: C)"

Class IIa

"1. EP testing is reasonable for diagnostic evaluation in patients with structurally normal hearts with palpitations or suspected outflow tract VT. (Level of Evidence: B)"

"2. Drug therapy with beta blockers and/or calcium channel blockers (and/or IC agents in RVOT VT) can be useful in patients with structurally normal hearts with symptomatic VT arising from the RV. (Level of Evidence: C)"

"3. ICD implantation can be effective therapy for the termination of sustained VT in patients with normal or near normal ventricular function and no structural heart disease who are receiving chronic optimal medical therapy and who have reasonable expectation of survival for more than 1 y. (Level of Evidence: C)"

Other Drug-Induced Toxicity (DO NOT EDIT)

Class I

"1. High intermittent doses and cumulative doses exceeding the recommended levels should be avoided in patients receiving anthracyclines such as doxorubicin. (Level of Evidence: B)"

"2. All patients receiving 5-fluorouracil therapy should receive close supervision and immediate discontinuation of the infusion if symptoms or signs of myocardial ischemia occur. Further treatment with 5-fluorouracil must be avoided in these individuals. (Level of Evidence: C)"

"3. Patients with known cardiac disease should have a full cardiac assessment including echocardiography, which should be undertaken prior to use of anthracyclines such as doxorubicin, and regular long-term follow-up should be considered. (Level of Evidence: C)"