Ventricular tachycardia
Tachycardia originating below the bundle of His, rate over 100 bpm, sustained (more than 30 seconds) or non-sustained. Per ESC Ventricular Arrhythmias 2022, stable sustained monomorphic VT – IV amiodarone; unstable – immediate electrical cardioversion. Foundation: cause control (ischaemia, electrolytes, drugs), beta-blockers, and ICD for high sudden death risk.
ICD-10 I47.25 drugs
Also known as: VT, Monomorphic VT
Drugs used for this condition
- BAmiodaroneSecond line · Class III antiarrhythmics (Vaughan Williams)Per ESC Ventricular Arrhythmias 2022, procainamide (class IIa) is preferred in haemodynamically stable sustained monomorphic VT, while amiodarone (class IIb) remains an alternative, mainly in patients with structural heart disease and reduced ejection fraction. IV 150 mg over 10 minutes, then 1 mg/min for 6 hours, then 0.5 mg/min for 18 hours (~1 g total day one). Electrical cardioversion is used immediately for haemodynamic instability. Long-term secondary prevention: ICD in high-risk patients; amiodarone is added to reduce ICD shock burden. With long-term use, monitor thyroid, lung, and liver function. Amiodarone potentiates warfarin (bleeding risk) and raises digoxin levels (risk of glycoside toxicity).
- BLidocaineSecond line · Amide-type local anaesthetic and class Ib antiarrhythmic (systemic use, codes C01BB01 and N01BB02)The FDA label for intravenous lidocaine names two settings: ventricular arrhythmias during cardiac manipulation such as cardiac surgery, and life-threatening arrhythmias of ventricular origin, in particular during acute myocardial infarction. The 2022 ESC guideline on ventricular arrhythmias names amiodarone as the first drug for sustained ventricular tachycardia with preserved haemodynamics and leaves lidocaine as an option when amiodarone is unavailable or unsuitable, particularly when the arrhythmia is ischaemic in origin, where its site of action works best. Prophylactic lidocaine in myocardial infarction is no longer given: that tactic lasted decades and was abandoned. The contraindications are firm: Stokes-Adams syndrome, Wolff-Parkinson-White syndrome, and severe sinoatrial, atrioventricular and intraventricular block.
- BMagnesium sulfateFirst line · Magnesium salt: intravenous solution and oral saline laxativeThe AEMPS Sulfato de Magnesio Altan label opens its indications with curative treatment of torsade de pointes. This is a particular ventricular tachycardia on a long QT background, and magnesium breaks it even when serum magnesium is normal: it suppresses the early afterdepolarisations that trigger the run. The 2022 ESC guidelines on ventricular arrhythmias hold the same line, adding withdrawal of the QT-prolonging drug, potassium repletion and overdrive pacing for pause-dependent episodes. In monomorphic ventricular tachycardia without QT prolongation magnesium does not do this. The label warns separately about patients on cardiac glycosides: there magnesium goes in with particular caution, above all alongside intravenous calcium salts.
- BSotalolSecond line · Non-selective beta blocker with class III antiarrhythmic activityTreats symptomatic ventricular arrhythmias and reduces shock frequency in patients with implantable cardioverter-defibrillators.
- CDisopyramideThird line · Class Ia antiarrhythmic with antimuscarinic activityDisopyramide is a third-line antiarrhythmic for ventricular tachycardia and atrial fibrillation when amiodarone, dronedarone and catheter ablation fail. AEMPS and ESC restrict use because of QT prolongation, neuropathy risk and pronounced antimuscarinic effects (especially in the elderly).
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit