Monomorphic Ventricular Tachycardia (VT) Treatment

Introduction

Monomorphic ventricular tachycardia (VT) is a life-threatening arrhythmia originating from the ventricles, characterized by a regular and uniform QRS morphology. Prompt recognition and appropriate treatment are crucial to prevent hemodynamic compromise, heart failure, or sudden cardiac death.

Causes and Risk Factors

• Structural heart disease (e.g., ischemic cardiomyopathy, prior myocardial infarction, cardiomyopathies)
• Ion channelopathies (e.g., Brugada syndrome, long QT syndrome)
• Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia)
• Drug-induced arrhythmias (e.g., antiarrhythmic drugs, QT-prolonging medications)
• Idiopathic VT (common in structurally normal hearts)

Diagnosis

• Electrocardiogram (ECG): Wide QRS complex tachycardia (>120 ms), rate >100 bpm
• Holter monitoring: For intermittent VT episodes
• Electrophysiology study (EPS): To assess inducibility and guide treatment
• Cardiac imaging (e.g., echocardiography, MRI): To evaluate structural heart disease

Treatment Options

1. Acute Management

• Hemodynamically unstable VT (Hypotension, shock, syncope, altered consciousness):
  • Immediate synchronized cardioversion (100-200J biphasic)
  • Advanced cardiac life support (ACLS) guidelines apply
• Hemodynamically stable VT:
  • Antiarrhythmic medications:
    • First-line: IV amiodarone (150 mg over 10 minutes followed by continuous infusion)
    • Alternative: IV lidocaine, procainamide (in case of ischemic VT)
  • Magnesium sulfate is considered (especially in torsades de pointes or hypomagnesemia)

2. Chronic Prevention

• Implantable cardioverter-defibrillator (ICD):
  • Recommended in patients with structural heart disease and a high risk of sudden cardiac death
• Catheter Ablation:
  • Useful for recurrent VT or drug-refractory cases
• Beta-blockers:
  • Especially in ischemic cardiomyopathy or long QT syndrome
• Antiarrhythmic Drugs:
  • Amiodarone or sotalol may be used in specific cases if ICD/ablation is not an option
• Lifestyle Modifications:
  • Electrolyte correction, avoiding QT-prolonging drugs, and managing underlying cardiac disease

Conclusion

The management of monomorphic VT requires urgent intervention if unstable and long-term preventive strategies for recurrence. Individualized patient assessment is key to optimal treatment.

References

Refer to the European and American guidelines for the latest recommendations.

Source recommendations

1. 2022 AHA/ACC/HRS Guideline for the Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

1. https://pubmed.ncbi.nlm.nih.gov/29084733/
2. https://www.sciencedirect.com/science/article/pii/S2405500X22010945
3. https://pubmed.ncbi.nlm.nih.gov/36017572/
4. https://www.heartrhythmjournal.com/article/S1547-5271(17)31249-3/fulltext
5. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Ventricular-Arrhythmias-and-the-Prevention-of-Sudden-Cardiac-Death

2. 2022 ESC Guidelines for the Management of Patients With Ventricular Arrhythmias and Sudden Cardiac Death

1. https://pubmed.ncbi.nlm.nih.gov/36017572/
2. https://academic.oup.com/eurheartj/article/43/40/3997/6675633
3. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Ventricular-Arrhythmias-and-the-Prevention-of-Sudden-Cardiac-Death
4. https://guardheart.ern-net.eu/wp-content/uploads/sites/4/2023/02/PMID-36017572_ESCGuideline_Zeppenfeld.pdf
5. https://www.ecrjournal.com/articles/comment-esc-guidelines-2022-management-patients-ventricular-arrhythmias-and-prevention?language_content_entity=en