Ventricular tachycardia

Ventricular tachycardia
Classification and external resources
ICD-10	I47.2
ICD-9	427.1
DiseasesDB	13819
eMedicine	emerg/634 med/2367 ped/2546
MeSH	D017180

Ventricular tachycardia (V-tach or VT) is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart. This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death.

Classification

12 lead electrocardiogram showing a run of monomorphic ventricular tachycardia (VT)

Ventricular tachycardia can be classified based on its morphology:

• Monomorphic ventricular tachycardia means that the appearance of all the beats match each other in each lead of a surface electrocardiogram (ECG).
  • RVOT tachycardia is a type of monomorphic ventricular tachycardia originating in the right ventricular outflow tract. RVOT morphology refers to the characteristic pattern of this type of tachycardia on an ECG.
• Polymorphic ventricular tachycardia, on the other hand, has beat-to-beat variations in morphology. This most commonly appears as a cyclical progressive change in cardiac axis, previously referred to by its French name torsades de pointes ("twisting of the points"). However, currently the term torsades is reserved for polymorphic VT occurring in the context of a prolonged resting QT interval.

Another way to classify ventricular tachycardias is the duration of the episodes: Three or more beats in a row on an ECG that originate from the ventricle at a rate of more than 100 beats per minute constitute a ventricular tachycardia.

• If the fast rhythm self-terminates within 30 seconds, it is considered a non-sustained ventricular tachycardia.
• If the rhythm lasts more than 30 seconds, it is known as a sustained ventricular tachycardia (even if it terminates on its own after 30 seconds).

A third way to classify ventricular tachycardia is on the basis of its symptoms: Pulseless VT is associated with no effective cardiac output, hence, no effective pulse, and is a cause of cardiac arrest. In this circumstance, it is best treated the same way as ventricular fibrillation (VF), and is recognized as one of the shockable rhythms on the cardiac arrest protocol. Some VT is associated with reasonable cardiac output and may even be asymptomatic. The heart usually tolerates this rhythm poorly in the medium to long term, and patients may certainly deteriorate to pulseless VT or to VF.

Less common is ventricular tachycardia which occurs in individuals with structurally normal hearts. This is known as idiopathic ventricular tachycardia and in the Monomorphic form appears with little or no incidence of increased risk of sudden cardiac death. In general, idiopathic ventricular tachycardia occurs in younger individuals diagnosed with VT. While the causes of idiopathic VT are not known, it is generally presumed to be congenital, and can be brought on by any number of diverse factors.

Pathophysiology

The morphology of the tachycardia depends on its cause.

In monomorphic ventricular tachycardia, all the beats look the same because the impulse is either being generated from increased automaticity of a single point in either the left or right ventricle, or due to a reentry circuit within the ventricle. The most common cause of monomorphic ventricular tachycardia is myocardial scarring from a previous myocardial infarction (heart attack). This scar cannot conduct electrical activity, so there is a potential circuit around the scar that results in the tachycardia. This is similar to the re-entrant circuits that are the cause of atrial flutter and the re-entrant forms of supraventricular tachycardia. Other rarer congenital causes of monomorphic VT include right ventricular dysplasia, and right and left ventricular outflow tract VT.

Polymorphic ventricular tachycardia, on the other hand, is most commonly caused by abnormalities of ventricular muscle repolarization. The predisposition to this problem usually manifests on the ECG as a prolongation of the QT interval. QT prolongation may be congenital or acquired. Congenital problems include Long QT syndrome and Catecholaminergic polymorphic ventricular tachycardia. Acquired problems are usually related to drug toxicity or electrolyte abnormalities, but can occur as a result of myocardial ischemia. Class III anti-arrhythmic drugs such as sotalol and amiodarone prolong the QT interval and may in some circumstances be pro-arrhythmic. Other relatively common drugs including some antibiotics and antihistamines may also be a danger, particularly in combination with one another. Problems with blood levels of potassium, magnesium and calcium may also contribute. High dose magnesium is often used as an antidote in cardiac arrest protocols.

Diagnosis

The diagnosis of ventricular tachycardia is made based on the rhythm seen on either a 12 lead EKG or a telemetry rhythm strip. It may be very difficult to differentiate between ventricular tachycardia and a wide-complex supraventricular tachycardia in some cases. In particular, supraventricular tachycardias with aberrant conduction from pre-existing bundle branch block are commonly misdiagnosed as ventricular tachycardia. Other rarer phenomena include ashman beats and antedromic atrioventricular re-entry tachcyardias.^{[citation needed]}

Various diagnostic criteria have been developed to determine whether a wide complex tachycardia is ventricular tachycardia or a more benign rhythm.^[1][2] In addition to these diagnostic criteria, if the individual has a past history of a myocardial infarction, congestive heart failure, or recent angina, the wide complex tachycardia is much more likely to be ventricular tachycardia.^[3]

The proper diagnosis is important, as the misdiagnosis of supraventricular tachycardia when ventricular tachycardia is present is associated with worse prognosis. This is particularly true if calcium channel blockers, such as verapamil, are used to attempt to terminate a presumed supraventricular tachycardia.^[4] It is therefore wisest to assume that all wide complex tachycardia is VT until proven otherwise.

Treatment

Therapy may be directed at either terminating an episode of the arrhythmia or for suppressing a future episode from occurring. The treatment for stable VT is tailored to the specific patient, with regard to how well the individual tolerates episodes of ventricular tachycardia, how frequently episodes occur, their comorbidities, and their wishes. Patients suffering from pulseless VT or unstable VT are hemodynamically compromised and require immediate cardioversion.

Synchronized electrical cardioversion

If the patient still has a pulse, it is usually possible to terminate a VT episode with a direct current shock across the heart. This is ideally synchronized to the patient's heartbeat. As this is quite uncomfortable, shocks should be delivered only to an unconscious or sedated patient. As a reminder, this is different from defibrillating the patient. If the patient still had a pulse, defibrillating the patient could potentially send him into asystole.

Defibrillation

A patient with pulseless VT or a ventricular fibrillation will be unconscious and treated as an emergency on an ACLS protocol, given high energy (360J with a monophasic defibrillator, or 200J with a biphasic defibrillator) unsynchronised cardioversion (defibrillation).

The shock may be delivered to the outside of the chest using an external defibrillator, or internally to the heart by an implantable cardioverter-defibrillator (ICD) if one has previously been inserted.

An ICD may also be set to attempt to overdrive pace the ventricle. Pacing the ventricle at a rate faster than the underlying tachycardia can sometimes be effective in terminating the rhythm. If this fails after a short trial, the ICD will usually stop pacing, charge up and deliver a defibrillation grade shock.

Cardiac ablation

Catheter ablation is a key therapeutic modality for patients with recurrent VT. A task force consisting of the European Heart Rhythm Association (EHRA) in conjunction with the Heart Rhythm Society (HRS) developed an expert consensus paper that carefully defines the indications, techniques, and outcomes of this procedure.^[5]

There was consensus among the task force members that catheter ablation for VT should generally be considered early in the treatment of patients with recurrent VT. In the past, ablation was often not considered until pharmacological options had been exhausted, often after the patient had suffered substantial morbidity from recurrent episodes of VT and ICD shocks. Antiarrhythmic medications can reduce the frequency of ICD therapies, but have disappointing efficacy and side effects. Advances in technology and understanding of VT substrates now allow ablation of multiple and unstable VTs with acceptable safety and efficacy, even in patients with advanced heart disease.^[6]

Remote magnetic navigation is recognized as an important method for delivery of ablation therapy for these patients due to the ability of the flexible magnetic catheter to carefully map the diseased tissue without inadvertently inducing abnormal ventricular rhythms. In a series of 110 patients that included all morphologies of VT, 85% of patients treated with magnetic ablation were free from VT at one year after the intervention and were exposed to statistically reduced levels of radiation when compared to non-magnetic VT ablations at the same center.^[7] In patients with myocardial scarring from a previous heart attack who were receiving excessive shocks from an ICD, magnetic ablation was shown to be successful in reducing these shocks and demonstrated a 67% reduction in imaging radiation needed to complete the procedure compared to a historical non-magnetic group.^[8] For monomorphic idiopathic VT which may originate in thin-walled tissues, magnetic ablation offers catheter flexibility, steering accuracy and reproducibility to navigate to a desired location with a low probability of perforating the myocardium.^[9]

Antiarrhythmic drug therapy

Drugs such as amiodarone or procainamide may be used in addition to defibrillation to terminate VT while the underlying cause of the VT can be determined. As hypomagnesia is a common cause of VT, stat dose magnesium sulphate can be given for torsades or if hypomagnesemia is found/suspected.

Long term anti-arrhythmic therapy may be indicated to prevent recurrence of VT. Beta-blockers and a number of class III anti-arrhythmics are commonly used. Lidocaine is now being replaced by amiodarone as the first line anti-arrhythmic treatment of VT.

The implantation of an ICD is more effective than drug therapy for prevention of sudden cardiac death due to VT and VF, but may be constrained by cost issues,(RDM) and well as patient co-morbidities and patient preference.

Popular culture

VT is frequently referenced in the 1970s television series Emergency!

In the 2006 film Casino Royale, the protagonist, James Bond, suffers ventricular tachycardia from intoxication of digitalis and goes into cardiac arrest.

"V-Tach" is what "The Satin Slayer" from the American soap opera All My Children used to kill his victims.^[10]

References

1. ^ Wellens HJ, Bar FW, Lie KI. (1978). "The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex". Am J Med 64 (1): 27–33. doi:10.1016/0002-9343(78)90176-6. PMID 623134. 
2. ^ Brugada P, Brugada J, Mont L, Smeets J, Andries EW. (1991). "A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex". Circulation 83 (5): 1649–59. PMID 2022022. 
3. ^ Baerman JM, Morady F, DiCarlo LA Jr, de Buitleir M. (1987). "Differentiation of ventricular tachycardia from supraventricular tachycardia with aberration: value of the clinical history". Ann Emerg Med 16 (1): 40–3. doi:10.1016/S0196-0644(87)80283-4. PMID 3800075. 
4. ^ Stewart RB, Bardy GH, Greene HL. (1986). "Wide complex tachycardia: misdiagnosis and outcome after emergent therapy". Ann Intern Med 104 (6): 766–71. PMID 3706928. 
5. ^ Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jaïs P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D; European Heart Rhythm Association; European Society of Cardiology; Heart Rhythm Society. “EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA).” Europace. 2009 Jun;11(6):771-817. Epub 2009 May 14. PMID 19443434
6. ^ Ibid: 6.
7. ^ Di Biase, L; Santangeli, P; Astudillo, V; Conti, S; Mohanty, P; Mohanty, S; Sanchez, JE; Horton, R et al. (2010). "Endo-epicardial ablation of ventricular arrhythmias in the left ventricle with the Remote Magnetic Navigation System and the 3.5-mm open irrigated magnetic catheter: results from a large single-center case-control series.". Heart rhythm : the official journal of the Heart Rhythm Society 7 (8): 1029–35. doi:10.1016/j.hrthm.2010.04.036. PMID 20434589. 
8. ^ Haghjoo, M; Hindricks, G; Bode, K; Piorkowski, C; Bollmann, A; Arya, A (2009). "Initial clinical experience with the new irrigated tip magnetic catheter for ablation of scar-related sustained ventricular tachycardia: a small case series.". Journal of cardiovascular electrophysiology 20 (8): 935–9. doi:10.1111/j.1540-8167.2008.01416.x. PMID 19175449. 
9. ^ Schwagten, BK; Szili-Torok, T; Rivero-Ayerza, M; Jessurun, E; Valk, S; Jordaens, LJ (2009). "Usefulness of remote magnetic navigation for ablation of ventricular arrhythmias originating from outflow regions.". Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation 17 (6): 245–9. PMC 2711250. PMID 19789687. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2711250. 
10. ^ Watkins, Karen. "All My Children Daily Recaps (Continued from Page 2): Monday, February 12, 2007 -- I THOUGHT IT WAS A TRICK....". About.com. http://allmychildren.about.com/od/dailyrecaps/a/bl20070212r_3.htm. Retrieved 2007-10-31.