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Acute management of ventricular tachycardia

Akutversorgung bei ventrikulärer Tachykardie

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Abstract

Acute management of patients with ventricular arrhythmia (VA) is aimed at immediate VA termination if the patient is hemodynamically instable and early termination after initial diagnostic work-up if tolerated. Prolonged episodes of VA may lead to hemodynamic and metabolic decompensation and early resumption of normal ventricular activation is warranted. Termination is best performed by electrical cardioversion, anti-tachycardia pacing (if available, in cases with an implanted defibrillator [ICD]) or defibrillation. Antiarrhythmic drug treatment may lead to rhythm stabilization in cases of VA recurrence. Scrutinizing the electrocardiogram (ECG) of VA is extremely helpful to differentiate potential mechanisms, underlying cardiac pathologies and identify treatment options, as well as a differential diagnosis if a ventricular origin is unclear. In general, structural VA should be differentiated from idiopathic and non-structural (idiopathic) VA. On the other hand, based on ECG morphology VA should be classified into monomorphic versus polymorphic ventricular tacyhcardia (VT)/ventricular fibrillation (VF). Polymorphic VT/VF may be related to reversible causes as well as genetically determined arrhythmia syndromes and a specialized treatment pathway may be chosen: (1) VA termination, (2) evaluation and treatment of potential VA causes, (3) acute (medical treatment) and chronic (interventional treatment using catheter ablation) prevention of recurrence and (4) treatment of underlying heart disease, if identified, are crucial pillars of VA management. These patients can be managed in dedicated VT units and by multispecialty teams integrating all potential aspects of rhythm stabilization and treating underlying cardiac abnormalities. Heart failure management in patients with reduced left ventricular function may be crucial for the long-term prognosis.

Zusammenfassung

Die Akutversorgung bei ventrikulären Arrhythmien (VA) richtet sich nach der hämodynamischen Toleranz. Bei hämodynamischer Instabilität ist eine sofortige Terminierung indiziert, ansonsten eine frühzeitige Terminierung nach initialer diagnostischer Aufarbeitung inklusive 12-Kanal-Elektrokardiogramm (EKG). Längere Episoden von VA können zur hämodynamischen und metabolischen Entgleisung bis zum kardiogenen Schock führen; eine schnelle Rückkehr zur normalen ventrikulären Stimulation wird angestrebt. Die Terminierung von VA erfolgt am besten mit einer elektrischen Kardioversion, Überstimulation (soweit verfügbar, in Fällen mit implantiertem Defibrillator) oder Defibrillation. Eine antiarrhythmische medikamentöse Therapie kann zur Rhythmusstabilisierung bei rezidivierenden VA-Episoden führen. Die genaue Analyse des EKGs der VA ist bei der Differenzierung des Mechanismus von großem Nutzen. Gleiches gilt in Bezug auf die Detektion einer möglichen zugrunde liegenden kardialen Erkrankung, die Abwägung möglicher Therapieoptionen und die Differenzialdiagnostik, wenn ein ventrikulärer Ursprung unsicher ist. Es sollten strukturelle von idiopathischen oder nichtstrukturellen VA differenziert werden. Auf Grundlage der EKG-Morphologie können monomorphe von polymorphen ventrikulären Tachykardien (VT) oder Kammerflimmern unterschieden werden. Generell können polymorphe VT oder Kammerflimmern potenziell reversible Ursachen haben oder mit genetisch determinierten Arrhythmiesyndromen zusammenhängen, die durch spezielle Interventionen therapierbar sind. 1. VA-Terminierung, 2. Evaluation und Behandlung potenzieller Ursachen, 3. akute (medikamentös) und langfristige (interventionell, z. B. mittels Katheterablation) Prävention von VA-Rezidiven und 4. Behandlung der zugrunde liegenden Herzerkrankung (falls vorhanden) sind kritische Bestandteile des VA-Managements. Die Patienten können in ausgewiesenen VT-Unit und von multidisziplinären Teams behandelt werden, die sämtliche potenziellen Aspekte der Rhythmusstabilisierung sowie der Behandlung zugrunde liegender Herzerkrankungen einbeziehen. Für die Langzeitprognose von VA-Patienten mit einer eingeschränkten linksventrikulären Funktion kann eine optimierte Herzinsuffizienzbehandlung essenziell sein.

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Authors and Affiliations

  1. Klinik für Interventionelle Elektrophysiologie, Rhön-Klinikum Campus Bad Neustadt, Von-Guttenberg-Str. 11, 97616, Bad Neustadt a. d. Saale, Germany

    Thomas Deneke, Karin Nentwich, Elena Ene, Artur Berkovitz, Kai Sonne & Philipp Halbfaß

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  1. Thomas Deneke
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  2. Karin Nentwich
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  3. Elena Ene
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Correspondence to Thomas Deneke.

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T. Deneke, K. Nentwich, E. Ene, A. Berkovitz, K. Sonne and P. Halbfaß declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Deneke, T., Nentwich, K., Ene, E. et al. Acute management of ventricular tachycardia. Herzschr Elektrophys 31, 26–32 (2020). https://doi.org/10.1007/s00399-020-00664-0

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