Inpatient / Cardiology
Ventricular Tachycardia (VTach)
#Ventricular Tachycardia 2/2 ***
-- Non-sustained VTach (NSVT) is >3 complexes for <30 seconds
-- Sustained VTach is >30 seconds
-- VT Storm is multiple sustained episodes of unstable VTach in 24 hours
-- Unstable if hypotension, AMS, chest pain, SOB/edema, new heart failure
Checklist:
-- ABCs: if unstable, get pads and cardiovert, push 50mcg fentanyl and 1-2mg midazolam for analgesia and sedation; if pulseless, defibrillate and give medicines per ACLS (epinephrine, amiodarone vs lidocaine)
-- Chart Check: prior VTach, MI/CAD, ADHF, ICD placement, anti-arrythmia drugs, QT-prolonging drugs,
-- Thorough HPI Intake: causes of hypoK and hypoMg, palpitations, shocks from ICD
-- Can't Miss: new ACS/MI, valvulopathy, severely prolonged QTc
-- Admission Orders: BMP, Mg, trop, EKG, tele, echo,
-- Initial Treatment to Consider: treat any wide complex like VTach unless you are sure its SVT with aberrancy; consider beta-blockade, amiodarone, lidocaine; if polymorphic, avoid QTc prolonging meds
Assessment:
-- History: *** prior VT, ACS/MI, CAD, HF; ICDs; anti-arrythmic medications, QTc prolonging meds
-- Clinical: *** hypotension, AMS, chest pain, SOB/edema,
-- Exam: *** appearance, diaphoresis, e/o overload, crackles,
-- Data: *** Hgb, Mg, Phos, echo, cath report
-- Etiology/DDx: *** ischemia, scar, prolonged QTc, hypokalemia, hypomagnesemia, indwelling lines against wall of chambers
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- BMP, Mg, trop, NT-proBNP
-- Ischemic workup - echo, stress, cath
-- If multiple runs of NSVT - echo, ambulatory monitoring
Treatment
-- Monomorphic VT - amiodarone 150mg IV bolus x2-3 -> 1mg/hr drip for 6 hours --> 0.5mg/hr drip for 18 hours --> PO 300 max daily VS lidocaine 1.0-1.5mg/kg bolus (usualyl 100mg) --> 1-4mg/hr drip (better if not sure monomorphic vs polymorphic and regardless of EF %; need to monitor for toxcitiy); patient should ultimately be on PO beta blockage, then add amiodarone, then can add mexiletine if still not anough; can discuss ablation with EP if ICD in place and still having episodes despite drugs
-- Polymorphic VT - mag 2-4g over 15 minutes; increase HR with dopamine, epinephrine; avoid bradycardia with BB's and avoid QTc prolonging meds incluing amiodarone
-- VT Storm - amiodarone 150mg IV bolus x2-3 -> 1mg/hr drip AND propranolol 60mg q6h; anti-tachycardia pacing (ATP) at higher rate than VT to break it; if above does not work, intubate and sedate
-- NSVT: if multiple runs and/or symptomatic - beta blockage; otherwise monitor
-- ICD: ** If the cause of VT is not clearyl identified and readily reversible, patient should have an ICD placed with EP - venous > subQ > LifeVest
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If You Remember Nothing Else
Ventricular Tachycardia can be an unstable rhythm leading to cardiac arrest. However, it can also be shortlived (NSVT), or sustained >30 seconds without leading to instability. VTach is most commonly caused by ischemia, scar, electrolyte abnormalities, and prolonged QTc. The treatment of monomorphic and polymorphic VT is different since they often have different etiologies. Unstable VTach is treated with cardioversion. Stable monomorphic VTach can be treated with anti-arryhthmics, most commonly amiodarone or lidocaine. Polymorphic Vtach or Torsades is treated with magnesium and lidocaine. In extreme cases, VT storm may require intubation and sedation. If the etiology is not readily apparent and reversible, most patients would benefit from having an ICD placed. In certain cases, ablation can also be considered.
Clinical Pearls
- Torsades can be caused by a PVC falling on the T wave of the previous beat - otherwsie called the R on T phenomenon
- Lidocaine may be the better choice over amiodarone if you are not sure whether it is monomorphic or polymorphic VT; it's also okay to use whether the patient has an EF greater or less than 40%
- Lidocaine toxicity - watch for neurotoxicity, namely changes in mental status
- Multiple runs of NSVT or any that are symptomatic should get an echo and ambulatory monitoring to assess for structural disease and assess frequency of events or presence of sustained VTach; if single asymptomatic episode, likely okay to monitor
- If you need to sedate for shocks - push 50mcg fentanyl and 1-2mg midazolam and have cardiac anesthesia available
- Amiodarone can prevent EP from inducing the arrythmia in the OR and at some instituions lidocaine is preferred as the first agent until it can be further evaluated; amiodarone can take time to wash out of the system delaying the placement of an ICD or an ablation
Trials and Literature
- VANISH Trial (NEJM, 2016) - ablation superior to escalation of anti-arrythmic drugs (lower rate of death, VT storm, and ICD shocks) in patients with history of MI and ICD placement and already on anti-arryhmic meds still having runs of VTach
- VEST Trial (NEJM, 2018) - wearable cardioverter-defibrillator did not prevent arryhthmic death in patients with EF <35% after MI (1.6% vs 2.4%); Of the 48 participants in the device group who died, 12 were wearing the device at the time of death; ICD is not recommended until 40-90 days after MI to see if EF will recover, thus this trial attempted to answer whether a wearable device could serve as a bridge in those with high risk of sudden cardiac death
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