Review Question - QID 104120

This patient with palpitations has a wide QRS complex rhythm on the electrocardiogram consistent with ventricular tachycardia. For hemodynamically stable patients with ventricular tachycardia, the most appropriate next step in management is initiation of an amiodarone infusion.

Ventricular tachycardia manifests on the electrocardiogram as a wide QRS complex (>120ms) rhythm. Ventricular tachycardia typically occurs in elderly patients with other comorbidities and is classified as hemodynamically stable, unstable, or pulseless. For hemodynamically stable patients such as this one, the most appropriate next step in management is initiation of an amiodarone infusion. Lidocaine or procainamide may also be utilized if amiodarone is contraindicated or not available. For hemodynamically unstable patients, synchronized cardioversion is the most appropriate next step. Pulseless ventricular tachycardia should receive standard cardiac arrest therapy including high quality CPR and early defibrillation. Epinephrine and amiodarone are also indicated. Of note, myocardial ischemia is a common cause of ventricular tachycardia. Patients presenting in ventricular tachycardia should be evaluated for myocardial ischemia with serial electrocardiograms and serum troponins.

Lo et. al review the association of ventricular tachycardia and ischemic heart disease. They note that ischemic heart disease is a common underlying condition in patients with ventricular tachycardia and recommend patients receive work-up for myocardial ischemia.

Figure/Illustration A demonstrates the wide QRS complex in wide complex ventricular tachycardia on the bottom ECG as compared to the normal QRS complex in a normal sinus rhythm in the top ECG.

Incorrect Answers:
Answer 1: Adenosine would be the best next step in management after vagal maneuvers for supraventricular tachycardia (SVT) in a stable patient. SVT presents with palpitations, a rapid heart rate, and a narrow QRS complex with a regular rate on the electrocardiogram.

Answer 3: Defibrillation would be indicated for management of pulseless ventricular tachycardia or ventricular fibrillation. For stable patients with ventricular tachycardia such as this one, defibrillation is not indicated.

Answer 4: Diltiazem is indicated in the management of atrial fibrillation with rapid ventricular response. While patients may present with symptoms similar to this patient's, the electrocardiogram will show an irregularly-irregular, narrow complex rhythm.

Answer 5: Synchronized cardioversion would be indicated for a patient with ventricular tachycardia and hemodynamic instability. For stable patients such as this one, synchronized cardioversion is not indicated.


Bullet Summary:
For hemodynamically stable patients with ventricular tachycardia, the most appropriate next step in management is initiation of an amiodarone infusion.