Wed3November0844PM 11

A 30-year-old man presents with a history of transient loss of consciousness and palpitations. His ECG shows ventricular tachycardia (VT).

Which of the following treatments should be avoided?

(Please select 1 option)

Amiodarone

DC cardioversion

Adenosine

Flecainide

Verapamil Correct

Explanation

Sustained ventricular tachycardia (VT) can result in haemodynamic collagpse and in general treatment depends on whether the patient is haemodynamically stable or unstable, and what the underlying cause is. All patients should have their electrolytes checked prior to attempting cardioversion (electrical or medical).

Patients who are unstable with VT should be treated immediately with DC cardioversion.

Treatment for stable patients depends on whether the VT is monomorphic or polymorphic, and whether left ventricular function is normal or impaired.

Stable patients with monomorphic VT should be treated with antiarrhythmics, such as IV procainamide or sotalol. Currently, amiodarone is preferred for patients with impaired LV function as procainamide can exacerbate cardiac failure. However, its use acutey is limited by its irritant nature on veins (are therefore ususal requirement for a central line). In addition, it is increasingly recognised that its effects on myocardial function and cardiac contractility are gradual in onset, which means other agents are often preferred. DC cardioversion is used in these patients if medical therapy is unsuccessful.

Patients with polymorphic VT with a normal QT interval are generally treated as those with monomorphic VT. Those with QT prolongation are treated with magnesium sulphate and/or pacing. Procainamide and amiodarone are contraindicated as they prolong the QT interval.

Verapamil should be avoided in cases of VT because it can cause a catastrophic fall in blood pressure.

Adenosine is useful diagnostically when the diagnosis of regular wide complex tachycardia is in doubt.

Flecainide is an effective antiarrhythmic, and can be used in those patients without LV failure (it is associated with an increased risk of death in such cases). However, it is most widely used for atrial fibrillation rather than in VT.

The limited information in the question stem makes exact management in this case tricky to determine. However, we know this is a young gentleman who is experiencing episodes of haemodynamic compromise and collapse. DC cardioversion is therefore the most appropriate option.

References & Further Reading:

Ventricular Tachycardia Treatment & Management

Answer Statistics

1

4%

2

7%

3

45%

4

17%

5

29%

Times answered: 283