Initial Treatment for Hemodynamically Unstable Ventricular Tachycardia

Assessment of Hemodynamic Stability

Signs of hemodynamic instability in patients with ventricular tachycardia include hypotension, acutely altered mental status, signs of shock, chest pain, or acute heart failure symptoms, according to the American Heart Association 2
If any of these signs are present, the patient should be considered unstable and requires immediate intervention, as recommended by the American Heart Association 2

The European Society of Cardiology recommends immediate synchronized direct-current cardioversion with appropriate sedation for patients with hemodynamically unstable ventricular tachycardia 1
This treatment is highly effective in terminating ventricular tachycardia and avoiding complications associated with antiarrhythmic drug therapy, with a strong evidence base 1, 3
Cardioversion should be considered early in the management of hemodynamically unstable patients, as recommended by the European Society of Cardiology 1

If the first cardioversion attempt is unsuccessful, the American Heart Association recommends repeat cardioversion with higher energy 4

After successful cardioversion, the American College of Cardiology recommends being vigilant for atrial or ventricular premature complexes that may trigger recurrence of ventricular tachycardia 5
For patients with recurrent ventricular tachycardia after cardioversion, the European Society of Cardiology recommends considering intravenous amiodarone, with a moderate strength of evidence 1
The European Society of Cardiology also recommends considering intravenous beta blockers if ischemia is suspected or cannot be excluded, with a moderate strength of evidence 1

For polymorphic ventricular tachycardia with hemodynamic compromise, the European Society of Cardiology recommends direct current cardioversion with appropriate sedation 1
If recurrent after conversion, the European Society of Cardiology recommends considering intravenous beta blockers, especially if ischemia is suspected, with a moderate strength of evidence 1
The European Society of Cardiology also recommends considering intravenous amiodarone in the absence of abnormal repolarization related to long QT syndrome, with a moderate strength of evidence 1
Urgent angiography is recommended if myocardial ischemia cannot be excluded, as recommended by the European Society of Cardiology 1

If the unstable ventricular tachycardia is torsades de pointes, the European Society of Cardiology recommends withdrawing any offending drugs and correcting electrolyte abnormalities 1
The European Society of Cardiology also recommends considering intravenous magnesium sulfate for patients with long QT syndrome, with a moderate strength of evidence 1
Acute pacing may be necessary for recurrent pause-dependent torsades de pointes, as recommended by the European Society of Cardiology 1

The European Society of Cardiology recommends not delaying cardioversion in hemodynamically unstable patients to attempt pharmacological conversion, with a strong evidence base 1
The European Society of Cardiology also recommends avoiding calcium channel blockers such as verapamil and diltiazem in patients with ventricular tachycardia, as they can worsen hemodynamic status, with a moderate strength of evidence 1
Proper synchronization of the cardioversion is crucial to avoid delivering the shock during the vulnerable period of the cardiac cycle, as recommended by the American Heart Association 4
Resuscitation equipment should be readily available as cardioversion may occasionally induce ventricular fibrillation or asystole, as recommended by the American Heart Association 4
Monitoring for transient depression of myocardial function is recommended, particularly with repeated shocks and higher energies, as recommended by the American Heart Association 4