Therapeutic target
- To correct the life-threatening cardiac arrhythmia, as it is considered a risk factor for sudden cardiac death.
Therapy recommendations
- Stable hemodynamic situation:
- Attempt therapy with amiodarone (first-line agent); this may facilitate cardioversion and/or prevent recurrence of ventricular tachycardia or fibrillation; not in shock or hyperthyroidism!
- If necessary, also ajmaline
- Unstable hemodynamic situation* :
- Immediate electrical cardioversion (synchronized biphasic at 120-150 J; if unsuccessful, up to maximum energy) required.
- Plus amiodarone if necessary
- Continuous therapy
- Amiodarone (III antiarrhythmic drug)
- Sotalol (beta blocker))
- To prevent recurrences (recurrence) of refractory tachycardic ventricular arrhythmias with a high risk of sudden cardiac death, implantation of an ICD (implantable cardioverter/defibrillator; pacemaker) is first-line therapy. [also possible without problems in awake patients.]
- Serum potassium and magnesium levels should be kept high normal.
- Upper body elevation, oxygen administration and intensive monitoring.
- “Eletrical storm” due to Brugada syndrome: quinidine and isoproterenol and prompt transfer to a cardiology center for VT ablation (= ablation of ventricular tachycardia) and to perform extracorporeal membrane oxygenation (ECMO; intensive care technique in which a machine takes over part or all of the respiratory function of patients)
- Torsades des Pointes: magnesium i.v., raising the base rate to 100/min by means of ICD.
- If necessary, catheter ablation (see below “Further therapy“).
- See also under “Further therapy“.
* Hemodynamically unstable
- Systolic blood pressure < 90 mmHg
- Impaired consciousness
- Chest pain
- Heart failure (cardiac insufficiency)
Other notes
- Polymorphic ventricular tachycardia secondary to a prolonged QT interval (= torsades-de-pointes tachycardia; torsarden) is a special case: i.v. magnesium (2 g over 10 min).
- Catecholaminergic polymorphic ventricular tachycardia (CPVT) [beta-blockers are first-line therapy]; flecaninide is an additional conservative therapeutic indication
- For fascicular ventricular tachycardia (also Belhassen tachycardia (BT)): Administration of verapamil for conversion. Thereafter, prophylactic therapy with a beta-blocker.Epidemiology: often young men aged 15-40 years; Clinic: occurrence paroxysmal (seizure-like): shortness of breath, fatigue or dizziness; Trigger: physical activity.
- Note: The ALPS trial demonstrated that both antiarrhythmic drugs, amiodarone and lidocaine, versus placebo did not significantly improve survival; neurologic outcome also showed no clear difference from placebo; at most, the data suggest a favorable trend for the antiarrhythmic drugs.