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Ventricular tachycardia

Last updated: February 16, 2021

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Ventricular tachycardia (VT) is a potentially life-threatening arrhythmia originating in the cardiac ventricles. VT usually results from underlying cardiac diseases, such as myocardial infarction or cardiomyopathy, but it can also be idiopathic or caused by drugs and electrolyte imbalances. Clinical manifestations range from palpitations and syncope to cardiogenic shock and sudden cardiac death (SCD). The characteristic ECG findings of VT are wide QRS complexes (> 120 ms), tachycardia (≥ 100/minute), and signs of AV dissociation. In the acute setting, management of VT may require immediate cardioversion, defibrillation, or administration of antiarrhythmic drugs. Most patients who develop symptomatic, recurrent VT require long-term therapy involving antiarrhythmic medication, cardioverter-defibrillator implantation, or catheter ablation of the arrhythmogenic focus. Torsades de pointes (TdP) is a type of polymorphic VT occurring in patients with a prolonged QT interval. Intravenous magnesium sulfate and correction of the underlying etiology of prolonged QTc are important aspects of TdP management.

Ventricular fibrillation is a type of ventricular tachyarrhythmia but is covered in a separate article (see “Ventricular fibrillation”).

Reference: [1]

Cardiac causes [1][2]

Ischemic heart disease is the most common cause of ventricular tachycardia. [1]

Extracardiac causes [2]

Drug-induced toxicity and electrolyte abnormalities are the most common extracardiac causes of ventricular tachycardia.

Mechanism

VT can result from an alteration in myocardial automaticity, electrical conduction, or ventricular repolarization secondary to several factors (see “Etiology” for details).

Effect

  • Asynchronous atrial and ventricular beats and rapid ventricular rhythm → ↓ blood flow into the ventricle during diastole cardiac output
  • Consequent hemodynamic compromise → symptoms of syncope, MI, angina

Reference [1]

If sustained VT is suspected, immediately obtain an ECG to confirm the diagnosis and initiate treatment as it can rapidly progress to ventricular fibrillation and cause sudden cardiac death.

Reference: [1]

The management of ventricular fibrillation and pulseless VT is the same and includes CPR and defibrillation.

Avoid procainamide and sotalol in patients with prolonged QT interval as they risk conversion of VT to torsades de pointes. [1]

Reference [1]

Approach

ECG [1]

An ECG should be obtained in all patients with suspected VT (ongoing or resolved). In an unstable patient, a rhythm strip allows for rapid assessment and initiation of emergency measures. In all stable or stabilized patients, a 12-lead ECG is essential for a detailed evaluation.

Characteristic findings during VT

3 consecutive wide QRS complexes at a frequency ≥ 100/minute and signs of AV dissociation confirm a diagnosis of VT. [12]

In wide-complex tachycardia, signs of AV dissociation help distinguish between VT (AV dissociation present) from SVT with aberrancy (AV dissociation absent). See “Brugada criteria” for further information.

Findings during sinus rhythm

Laboratory studies [1]

Imaging [1]

  • Indications: all patients with confirmed VT to assess LVEF and evaluate for structural cardiac defects [13]
  • Modalities
  • Findings: Variable; may include valvular defects, regional wall motion abnormalities, ↓ LVEF, and evidence of myocardial infiltration, scarring, or inflammation.

Further assessment of suspected arrhythmia [1][13]

If there is any doubt regarding the diagnosis, assume VT rhythm and treat accordingly.

The differential diagnoses listed here are not exhaustive.

Approach [1]

Long-term management of patients with VT

Pharmacological therapy (antiarrhythmics) is often used alongside device therapy (e.g., ICD) to minimize symptoms, risk of recurrence, and risk of sudden cardiac death. Ablation of the arrhythmogenic foci is potentially curative.

Pharmacological therapy [1][13]

Medications to minimize VT recurrence [1][13]
Drug class Indications Medications
Safe in known heart disease β-blockers
Amiodarone
Caution in known heart disease

Sotalol

(class III antiarrhythmic)

Class Ic antiarrhythmics
Calcium channel blockers

Implantable cardioverter-defibrillator (ICD) [1]

Ablation [1][17]

  • Overview
    • Potential curative treatment for VT
    • Most patients do not subsequently require an ICD or further antiarrhythmic therapy. [18][19]
    • Following an EP study, the arrhythmogenic focus is ablated.
  • Indications
    • Recurrent VT despite optimal therapy
    • Antiarrhythmics are not tolerated
    • Patient preference
  • Options

Torsades de pointes (TdP) [1][6]

We list the most important complications. The selection is not exhaustive.

Initial assessment

  • Assess for hemodynamic stability and signs of unstable tachycardia.
  • Obtain an ECG (rhythm strip in unstable patients; 12-lead ECG in stable patients).
  • Urgently consult cardiology.
  • See “Approach to tachycardia” for detailed instructions on the initial evaluation of a tachyarrhythmic patient.

Hemodynamically unstable patients

Hemodynamically stable patients

Subsequent management

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