APPROACH TO VTACH: DX & MANAGEMENT PEARLS!

AM Report Pearls: Approach to Ventricular Tachycardia – Diagnosis:

  1. Stable or unstable? If unstable (hypotension, chest pain, or altered mental status), proceed with ACLS and assume it’s VT!

o   In general, if patient is unstable, assume it’s VT, and if patient is stable, you have more time to figure it out & is more likely to be SVT BUT you can be fooled with slow VT!

  1. Any risk factors for VT?(e.g. Prior MI, prior cardiac surgery, known scars)? If so, assume it’s VT!
  2. Do they have a prior EKG with an old LBBB or old RBBB?If the patient is stable AND has an old bundle branch block, more likely to be SVT with aberrancy
  3. Check for capture or fusion beats: If these are present, it’s VT. these beats have the highest positive predictive value for VT.
  4. Check for A-V dissociation: A-V dissociation is not required for VT, but is strongly suggestive
  5. Check for concordance: Look for concordant morphology in leads V1-V6 (i.e. all negative or all positive)
  6. R wave in aVR present aka “Up in aVR”? This is the Vereckei criteria which is a quick tip for seeing if VT as well!
  7. If you’ve made it this far, patient is stable, and still not sure, now you can bust out Brugada criteria!

For more reading if you are a true Cardiology nerd, I recommend ECGPedia.org – this article is a good one! http://en.ecgpedia.org/wiki/Approach_to_the_Wide_Complex_Tachycardia#Vereckei_aVR_algorithm_.5B5.5D

AM Report Pearls: Approach to Ventricular Tachycardia – Management:

  • As above, first check if stable or unstable, if unstableàACLS protocol
  • If stable, see if sustained (>30 seconds) or non-sustained VT (<30 seconds) on EKG
  • Assess via TTE if heart is structurally normal or not
  • Evaluate all patients with VT for ischemia since majority of patients with VT and structural heart disease have CAD
  • EP studies are not recommended if clear diagnosis of VT by EKG and if you are already planning on ICD placement
  • There is a mortality benefit in using AICDs in patient with recurrent VT/VF
  • Antiarrhythmic drugs can help treat patients with symptomatic VT and can reduce incidence of ICD shocks in patients with AICD

o   Most common drugs  are IV/PO amiodarone and PO sotalol (both class III antiarrhythmics that prolong the action potential duration) and IV lidocaine (class IB) – choose the drugs according to risks/benefits & route of entry

o   The AVID trial of secondary prevention showed that dual ICD+anti-arrhythmic drug therapy reduced arrhythmias

o   SCD-HeFT trial showed that amiodarone did not reduce mortality in patients with VT and reduced EF as opposed to ICD or placebo – ICD is preferred to amio alone

o   Note that sotalol is renally cleared – caution!

  • Class I Indications for AICD placement for VT:

o   Post-arrest patients with VFib or unstable VT

o   Patients with structural heart disease AND spontaneous sustained VT, whether stable OR unstable

o   Patients with symptomatic hemodynamically significant sustained VT or VF induced on EP study

o   Patients with nonsustained VT due to prior MI + EF < 40+ inducible VF/VT on EP study

o   For all indications for AICD, please check out the latest guidelines at http://circ.ahajournals.org/content/117/21/2820.full

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