Ventricular tachycardia guidelines in treatment


 * Associate Editor-in Chief: Avirup Guha, M.B.B.S.[mailto:avirup.guha@gmail.com]

==Guidelines in Ventricular Tachycardia Treatment ==

Recommendations in Ablation of Ventricular Tachycardia
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Class I
1. Ablation is indicated in patients who are otherwise at low risk for Sudden Cardiac Death(SCD) and have sustained predominantly monomorphic ventricular tachycardia that is drug resistant, who are drug intolerant, or who do not wish long-term drug therapy.(Level of Evidence: C)

2. Ablation is indicated in patients with Bundle branch reentrant ventricular tachycardia.(Level of Evidence: C)

3. Ablation is indicated as adjunctive therapy in patients with an Implantable cardioverter-defibrillator(ICD) who are receiving multiple shocks as a result of Sustained VT that is not manageable by reprogramming or changing drug therapy or who do not wish long-term drug therapy. (Level of Evidence: C)

4. Ablation is indicated in patients with WPW syndrome resuscitated from sudden cardiac arrest due to AF and rapid conduction over the accessory pathway causing VF. (Level of Evidence: B))

Class IIa
1. Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have symptomatic nonsustained monomorphic VT that is drug resistant, who are drug intolerant or who do not wish long-term drug therapy.(Level of Evidence: C)

2. Ablation can be useful therapy in patients who are otherwise at low risk for SCD and have frequent symptomatic predominantly monomorphic PVCs that are drug resistant or who are drug intolerant or who do not wish long-term drug therapy.(Level of Evidence: C)

3. Ablation can be useful in symptomatic patients with WPW syndrome who have accessory pathways with refractory periods less than 240 ms in duration. (Level of Evidence: B)

Class IIb
1. Ablation of Purkinje fiber potentials may be considered in patients with ventricular arrhythmia storm consistently provoked by PVCs of similar morphology. (Level of Evidence: C)

2. Ablation of asymptomatic PVCs may be considered when the PVCs are very frequent to avoid or treat tachycardia-induced cardiomyopathy. (Level of Evidence: C)

Class III
Ablation of asymptomatic relatively infrequent PVCs is not indicated. (Level of Evidence: C)}}

Recommendations for Acute Management Of Ventricular Tachycardia(and other arrhythmias)
{{cquote| ===2006 Guidelines ===

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

===2010 Guidelines(from the section on cardioversion and wide complex tachycardia only - incomplete and will be made better once the new guidelines after 2006 are released) ===

Class IIa
1.Cardioversion with monophasic waveforms should begin at 200 J and increase in stepwise fashion if not successful. (Level of Evidence: B)

2.If the etiology of the rhythm cannot be determined, the rate is regular, and the QRS is monomorphic, recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis. (Level of Evidence: B)

3.If IV antiarrhythmics are administered, procainamide can be considered. (Level of Evidence: B)

4.If antiarrhythmic therapy is unsuccessful, cardioversion or expert consultation should be considered. (Level of Evidence: C)

Class IIb
1.Monomorphic VT with a pulse responds well to monophasic or biphasic waveform cardioversion(synchronized) shocks at initial energies of 100 J. If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion. (Level of Evidence: C)

2.Precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia if a defibrillator is not immediately ready for use. (Level of Evidence: C)

3.If IV antiarrhythmics are administered, amiodarone or sotalol can be considered. (Level of Evidence: B)

Class III
1.Adenosine should not be given for unstable or for irregular or polymorphic ventricular tachycardias, as it may cause degeneration of the arrhythmia to VF. (Level of Evidence: C)

2.Verapamil is contraindicated for wide-complex tachycardias unless known to be of supraventricular origin. (Level of Evidence: B)

3.If one of these antiarrhythmic agents is given, a second agent should not be given without expert consultation. (Level of Evidence: B)}}

Ventricular Tachycardia Associated With Low Troponin Myocardial Infarction
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Class I
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
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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 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
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)

Class III
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)}}

Repetitive Monomorphic Ventricular Tachycardia
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Class IIa
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 VT
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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
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
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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 mmol/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 with LQT3 and torsades de pointes. (Level of Evidence: C)}}

Incessant Ventricular Tachycardia
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Class I
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
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)}}

Category : Electrophysiology