What are the long-term treatment options for ventricular tachycardia (VT)?

Updated: Dec 05, 2017
  • Author: Steven J Compton, MD, FACC, FACP, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
  • Print
Answer

Patients with monomorphic ventricular tachycardia (VT) who have structurally normal hearts are at a low risk of sudden death. Consequently, implantable cardioverter-defibrillators (ICDs) are rarely necessary in this setting; these patients are almost always managed with medications or ablation.

Antiarrhythmic drug trials have been disappointing, particularly in patients with left ventricular dysfunction. Some antiarrhythmic drugs may actually increase sudden-death mortality in this group. This is a particular concern with Vaughan Williams class I antiarrhythmics, which slow propagation and reduce tissue excitability through sodium-channel blockade. For most patients with left ventricular dysfunction, current clinical practice favors class III antiarrhythmics, which prolong myocardial repolarization through potassium-channel blockade. [65]

Amiodarone is a complex antiarrhythmic drug that deserves special mention. It is generally listed as a class III agent but has measurable class I, II, and IV effects. Unlike class I antiarrhythmics, amiodarone appears to be safe in patients with left ventricular dysfunction.

Amiodarone, when used in combination with beta blockers, can be useful for patients with left ventricular dysfunction due to previous myocardial infarction (MI) and symptoms due to VT that do not respond to beta blockers. [40]

In the Electrophysiologic Study versus Electrocardiographic Monitoring (ESVEM) trial, which compared long-term treatment with seven antiarrhythmic drugs (not including amiodarone) in patients with VT, the risks of adverse drug effects, arrhythmia recurrence, or death from any cause were lowest with sotalol. [65] The other antiarrhythmic drugs studied in the ESVEM trial were imipramine, mexiletine, pirmenol, procainamide, propafenone, and quinidine.

In patients with heart failure, the best-proven—albeit nonspecific—antiarrhythmic drug strategies include the use of the following:

  • The beta receptor–blocking drugs carvedilol, metoprolol, and bisoprolol
  • Angiotensin-converting enzyme (ACE) inhibitors
  • Aldosterone antagonists

Statin therapy is advantageous in patients with coronary heart disease, to reduce the risk of vascular accidents, ventricular arrhythmias (possibly), and sudden cardiac death. [40]

Although idiopathic VTs often respond to verapamil, this agent may cause hemodynamic collapse and death when administered to treat VT in patients with left ventricular dysfunction. Therefore, verapamil (or any other calcium-channel blockers) is contraindicated in any patient with wide-complex tachycardia of uncertain etiology. [54]


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!