V Tach
This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation and sudden death. Although less common, some forms of this arrhythmia appear benign, especially in young individuals.
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).
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, referred to by its French name torsades de pointes ("twisting of the points").
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 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.
The most common cause of monomorphic ventricular tachycardia is damaged or dead (scar) tissue 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.
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 repolarisation. The predisposition to this problem usually manifests on the ECG as a prolongation of the QT interval.
Acquired problems are usually related to drug toxicity or electrolyte abnormalities, but can occur as a result of myocardial ischaemia. 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.
Other rarer phenomena include ashman beats and antedromic atrioventricular re-entry tachcyardias.
Various diagnostic criteria have been developed to determine whether a wide complex tachycardia is ventricular tachycardia or a more benign rhythm. 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.
The proper diagnosis is important, as the misdiagnosis of supraventricular tachycardia when ventricular tachycardia is present is associated with worse prognosis. The treatment 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.
Electrical Cardioversion / Defibrillation
It is usually possible to terminate a VT episode with a direct current shock across the heart.
As this is quite uncomfortable, shocks should be delivered only to an unconscious or sedated patient. Elective cardioversion is usually performed in controlled circumstances with anaesthetic and airway support.
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.
Antiarrhythmic drug therapy
Drugs such as amiodarone or Procainomide may be used in addition to defibrillation to terminate VT while the underlying cause of the VT can be determined.
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.
For some of the rare congenital syndromes of VT, other drugs, and sometimes even catheter ablation therapy may be useful.
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, though the sequence shown in the film of progression from ventricular tachycardia to cardiac arrest is incorrect. "V-Tach" is a commonly used term in the television shows Grey's Anatomy, Scrubs, ER and House.
"V-Tach" is what the "The Satin Slayer" on the American soap opera All My Children used to kill his victims.
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