AHA Ventricular Arrhythmia Guidelines – What You Need to Know

Written by Thomas Davis, MD.

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The AHA has released new guidelines for management of ventricular arrhythmias.  Here is what you need to know.

Ground Rules – Definitions and Core Knowledge

1. ACS generally causes VF or polymorphic VT.  A scar from an old MI generally causes monomorphic VT.
2. VT/VF storm generally occurs within 3 months of an MI. It is defined as >/= 3 episodes of sustained VT, VF, or appropriate ICD shocks in a 24-hour period.

Summary – 180 Pages in 180 Words

1. If in doubt with wide complex tachycardia, assume it’s VT (class I).
2. For hemodynamically stable VT, procainamide is the preferred pharmacologic agent (class IIa). However, cardioversion remains a class I recommendation.
3. In hemodynamically unstable ventricular arrhythmias, electricity is undoubtedly first priority. If that fails, amiodarone is the preferred pharmacologic agent (class IIa).
4. IV beta blockers may be useful (class IIa) for patients with:
   1. VT/VF storm despite DCCV and antiarrhythmics
   2. Polymorphic VT due to MI
5. Epinephrine 1mg every 3-5 minutes “may be reasonable” in cardiac arrest (class IIb).
6. Consider emergent PCI in all patients after out-of-hospital cardiac arrest, particularly with initial shockable rhythm.  Absence of STEMI does not rule out culprit coronary lesion and may be seen in 30% of patients.
7. Contrary to common teaching, accelerated idioventricular rhythm (AIVR) is not a marker of reperfusion. Instead it is more strongly associated with infarct size.
8. Some drugs can worsen or unmask Brugada syndrome. Check out brugadadrugs.org for a complete list. Common culprits: procainamide, flecainide, TCAs, lithium, propofol, cocaine, cannabis, alcohol.
9. Digoxin isn’t the only cause of bidirectional VT. Catecholaminergic polymorphic VT (exercise or stress induced VT) can also cause it.
10. Long QT syndrome: males in childhood and postpartum females are at greatest risk for ventricular arrhythmia. 

Source
2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.  Circulation. 2017 Oct 30. pii: CIR.0000000000000549. doi: 10.1161/CIR.0000000000000549. [Epub ahead of print]

Peer reviewed by Clay Smith, MD.