Pharmacological Treatment for Tachycardia with Pulse

Introduction to Tachycardia Treatment

The European Society of Cardiology and American College of Cardiology recommend amiodarone as the preferred antiarrhythmic for hemodynamically stable ventricular tachycardia (VT), particularly in patients with structural heart disease or heart failure 1

Before any pharmacological intervention, hemodynamic stability must be determined by assessing for adverse signs, including hypotension, chest pain, acute heart failure, altered mental status, and signs of shock 1, 2

The American College of Cardiology recommends amiodarone as the first-line treatment for stable VT, with a dosing regimen of 150 mg IV over 10 minutes, followed by a maintenance infusion of 1.0 mg/min for 6 hours, then 0.5 mg/min 1, 3
The European Society of Cardiology suggests combining amiodarone with IV beta-blockers for optimal efficacy 1
Procainamide demonstrates the greatest efficacy among medical options for stable monomorphic VT, with a loading infusion of 20-30 mg/min up to a maximum 10-17 mg/kg, but reduce infusion rates in patients with renal dysfunction 1, 3
Lidocaine is relegated to second-line status and is particularly useful when VT is thought to be ischemia-related, with an initial bolus of 1.0-1.5 mg/kg IV and a maintenance infusion of 2-4 mg/min 1, 2, 3

The American College of Cardiology recommends vagal maneuvers as the first attempt to treat stable SVT, followed by adenosine as the first-line drug, with a dosing regimen of 3 mg rapid IV bolus with saline flush 2, 4
Adenosine is contraindicated in asthmatics due to the risk of bronchospasm 2, 4

The American Heart Association advises against using calcium channel blockers, adenosine, and class IC antiarrhythmics in wide-complex tachycardia/VT due to the risk of precipitating ventricular fibrillation or profound hypotension 1, 2, 3

The European Society of Cardiology recommends magnesium 8 mmol (2 grams) IV bolus immediately for torsades de pointes (polymorphic VT with long QT), especially if hypomagnesemia is suspected 1, 3
The American College of Cardiology suggests using IV beta-blockers combined with amiodarone as the first-line treatment for VT storm (recurrent/incessant VT) 3

The American College of Cardiology recommends always following IV drugs with 20 mL saline bolus to aid delivery to central circulation, and correcting electrolytes before and during therapy 1, 2, 4
The European Society of Cardiology advises keeping cardioversion equipment immediately available when administering any antiarrhythmic, and monitoring continuously for hypotension, bradycardia, and AV block during antiarrhythmic administration 1