Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Is Amiodarone the Best Drug for Stable Ventricular Tachycardia

Is Amiodarone the Best Drug for Stable Ventricular Tachycardia?

What do the cardiologists recommend?

D. Sustained Monomorphic Ventricular Tachycardia
Recommendations

Class I

1. Wide-QRS tachycardia should be presumed to be VT if the diagnosis is unclear. (Level of Evidence: C)

2. Direct-current cardioversion with appropriate sedation is recommended at any point in the treatment cascade in patients with suspected sustained monomorphic VT with hemodynamic compromise. (Level of Evidence: C)

Class IIa

1. Intravenous procainamide (or ajmaline in some European countries) is reasonable for initial treatment of patients with stable sustained monomorphic VT. (Level of Evidence: B)

2. Intravenous amiodarone is reasonable for patients with sustained monomorphic VT that is hemodynamically unstable, refractory to conversion with countershock, or recurrent despite procainamide or other agents. (Level of Evidence: C)

3. Transvenous catheter pace termination can be useful to treat patients with sustained monomorphic VT that is refractory to cardioversion or is frequently recurrent despite antiarrhythmic medication. (Level of Evidence: C)[1]

Class I –

Cardioversion.

Class IIa –

1. Procainamide.
2. Amiodarone.
3. Transvenous pacer.

OK, but that is not from the current ACLS.

Amiodarone must have been moved up in the rankings in the current ACLS, because that is what we were taught.

The guidelines above came out in 2006.

Amiodarone was was not moved up, but was downgraded to Class IIb in the current (2010) ACLS Guidelines.


Image modified from Paramedicine 101 – 2010 AHA Updates.

For patients who are stable with likely VT, IV antiarrhythmic drugs or elective cardioversion is the preferred treatment strategy. If IV antiarrhythmics are administered, procainamide (Class IIa, LOE B), amiodarone (Class IIb, LOE B), or sotalol (Class IIb, LOE B) can be considered. Procainamide and sotalol should be avoided in patients with prolonged QT. If one of these antiarrhythmic agents is given, a second agent should not be given without expert consultation (Class III, LOE B). If antiarrhythmic therapy is unsuccessful, cardioversion or expert consultation should be considered (Class IIa, LOE C).[2]

Class I –

Still cardioversion.

Class IIa –

Procainamide.

Class IIb –

Amiodarone.

Maybe in the 2015 ACLS Guidelines there will not be any mention of amiodarone, except as a historical footnote. Maybe amiodarone will be replaced by something more effective at treating ventricular tachycardia, such as adenosine. 😳

More likely is that we use more procainamide, but we should also consider being much more aggressive in sedating patients in anticipation of cardioversion. Amiodarone is associated with improvement from ventricular tachycardia in less than 30% of patients with stable ventricular tachycardia.

We need better sedatives. Ketamine would probably be the safest sedative for EMS to use.

Why don’t more of us have ketamine?

Footnotes:

[1] D. Sustained monomorphic ventricular tachycardia
XIII. Acute management of specific arrhythmias
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death–executive summary: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology/American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association and the Heart Rhythm Society.
Eur Heart J. 2006 Sep;27(17):2099-140. No abstract available.
PMID: 16923744 [PubMed – indexed for MEDLINE]

Free Full Text from European Heart Journal with link to PDF Download

[2] Therapy for Regular Wide-Complex Tachycardias
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.3: Management of Symptomatic Bradycardia and Tachycardia
Wide-Complex Tachycardia (Figure 4, Boxes 5, 6, and 7)
Free Full Text from Circulation with link to PDF Download

.

Comments

  1. I just gave procainamide in the ER a few weeks ago, partly because it seemed like the best drug for the odd situation, but also just to get people back into the habit of using it. When a trauma/CC surgeon heard I was giving it, he said “You’re not old enough to give procainamide!”

    Well, stick around long enough, and the passe becomes hip again.

    By the way, you might appreciate Rob Orman’s podcast ERCAST, where he talks about treating refractory AF. (http://blog.ercast.org/2010/12/v-tach-storm/)

  2. you speak of adenosine in VT? thats not a goog choice. its uneffective because it only does a totally blockade of av-node. I use adenosine in svt or in svt with wide qrs komplexes to see if the tachycardia is svt or vt. (in vt adenosine doesnt work)

    • Rainer Holzapfel,

      you speak of adenosine in VT? thats not a good choice. its uneffective because it only does a totally blockade of av-node. I use adenosine in svt or in svt with wide qrs komplexes to see if the tachycardia is svt or vt. (in vt adenosine doesnt work)

      That is not true.

      Adenosine-sensitive VT

      – Well-documented in the cardiology (EP)
      literature

      – Often are young patients, no underlying CAD

      – Hina, et al (Jpn Heart J, 1996)
      •  terminated VT in 5 out of 10 adult patients

      – Lenk, et al (Acta Paediatr Jpn, 1997)
      •  terminated VT in 5 out of 8 pediatric patients

      ECG Cases that Would Make an Electrophysiologist Blush
      Amal Mattu
      Presentation at ACEP Scientific Assembly
      10/15/2011
      p 28/103
      Free PDF Download from ACEP

      I will write more about this.

      .

  3. Throw in the long half life and increased occurances of toresades on the pile as well. I’ve seen a good vagal manuever work more often than not.

    • westcoastflmedic,

      Throw in the long half life and increased occurances of toresades on the pile as well. I’ve seen a good vagal manuever work more often than not.

      In the link from Doc Cottle, there is a discussion of treatment of refractory V Tach.

      That may have something to do with what a cardiologist is reported to have said about treatment of V Tach – that beta blockers should always be used. I am uncomfortable with any always, or never, recommendation, but this is a bit different from the way we usually think of ACLS. Sotalol (another primarily Class III drug) is a beta blocker, too.

      Amiodarone is the napalm antiarrhythmic – it is essentially a Vaughn-Williams Class Everything drug. If the conduction can be affected, amiodarone will affect it. While primarily listed as a Class III drug, amiodarone also has Class I, Class II, and Class IV properties.

      Vagal maneuvers are related to adenosine.

      By the way, you might appreciate Rob Orman’s podcast ERCAST, where he talks about treating refractory VT. (http://blog.ercast.org/2010/12/v-tach-storm/)

      .

Trackbacks

  1. […] the comments to Is Amiodarone the Best Drug for Stable Ventricular Tachycardia is the following from Doc Cottle of Mill Hill Ave […]

Speak Your Mind