Ventricular tachycardia

Cardiovascular

Clinicals - History

Fact Explanation
May have a congential etiology When ventricles beat very fast (120 to 300 beats per minute), and neither coordinated with the atria it is called a ventricular tachycardia. Most commonly VT is seen in a weak cardiac musculature due to a cardiomyopathy, or when there's scarring of the heart due to prior myocardial infarction. But channelopathies,electrolyte imbalances, structural heart disease such as tetralogy of Fallot, systemic diseases such as rhematoid arthritis, certain drugs can also cause a VT. The pathophysiology of the arrhythmia is usually caused by electrical reentry or abnormal automaticity. Inherited channelopathies such as long/short QT syndromes, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome have a congenital etiology. When there's beat to beat variation of the QRS complex, it's called polymorphic VT and if similar it's called monomorphic VT May have a congential etiology
When ventricles beat very fast (120 to 300 beats per minute), and neither coordinated with the atria it is called a ventricular tachycardia. Most commonly VT is seen in a weak cardiac musculature due to a cardiomyopathy, or when there's scarring of the heart due to prior myocardial infarction. But channelopathies,electrolyte imbalances, structural heart disease such as tetralogy of Fallot, systemic diseases such as rhematoid arthritis, certain drugs can also cause a VT. The pathophysiology of the arrhythmia is usually caused by electrical reentry or abnormal automaticity. Inherited channelopathies such as long/short QT syndromes, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome have a congenital etiology. When there's beat to beat variation of the QRS complex, it's called polymorphic VT and if similar it's called monomorphic VT
Palpitations Sensation of pounding of the heart is due to abnormal rhythm Palpitations
Sensation of pounding of the heart is due to abnormal rhythm
Light-headedness/ Syncope Due to cerebral hypo-perfusion due to extreme tachycardia Light-headedness/ Syncope
Due to cerebral hypo-perfusion due to extreme tachycardia
Chest pain Can be due to ischaemia or palpitations it self Chest pain
Can be due to ischaemia or palpitations it self
Anxiety Due to palpitations Anxiety
Due to palpitations
Sudden death In catecholaminergic polymorphic ventricular tachycardia (CPVT) there can be episodes of syncope, seizures, or sudden death Sudden death
In catecholaminergic polymorphic ventricular tachycardia (CPVT) there can be episodes of syncope, seizures, or sudden death

Clinicals - Examination

Fact Explanation
Tachycardia VT is usually caused by electrical reentry or abnormal automaticity and this results in tachycardia Tachycardia
VT is usually caused by electrical reentry or abnormal automaticity and this results in tachycardia
Hypotension Prolonged VT could result in hypotension due to incomplete filling and incoordinated contractions. Hypotension
Prolonged VT could result in hypotension due to incomplete filling and incoordinated contractions.
Tachypnoea Prolonged VT could result in increased respiratory rate Tachypnoea
Prolonged VT could result in increased respiratory rate
diaphoresis Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion and resultant increased sweating diaphoresis
Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion and resultant increased sweating
Pallor Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion and pallor Pallor
Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion and pallor
Diminished level of consciousness Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion to brain and diminished level of consciousness Diminished level of consciousness
Sometimes patients may present with haemodynamic instability due to prolonged VT and reduced cardiac output due to tachycardia result in poor perfusion to brain and diminished level of consciousness
Elevated jugular venous pressure with cannon a waves This is observed if atria are in sinus rhythm Elevated jugular venous pressure with cannon a waves
This is observed if atria are in sinus rhythm
Murmers When a valvular disease or hypertrophic obstructive cardiomyopathy causes the VT, murmurs may be heard. Murmers
When a valvular disease or hypertrophic obstructive cardiomyopathy causes the VT, murmurs may be heard.
Displaced apex Due to cardiomegaly due to underlying ischaemic heart disease Displaced apex
Due to cardiomegaly due to underlying ischaemic heart disease
Rales on respiratory system examination If the arrhythmia leads to congestive cardiac failure, auscultation of lungs may reveal rales Rales on respiratory system examination
If the arrhythmia leads to congestive cardiac failure, auscultation of lungs may reveal rales
Varying intensity of the first heart sound Due to loss of atrioventricular (AV) synchrony. Varying intensity of the first heart sound
Due to loss of atrioventricular (AV) synchrony.

Investigations - Diagnosis

Fact Explanation
Electrocardiography (ECG Broad complex tachycardia (BCT) is seen. Some of ECG differential diagnosis are supraventricular tachycardia (SVT) with aberrant conduction and bundle branch block (BBB) Electrocardiography (ECG
Broad complex tachycardia (BCT) is seen. Some of ECG differential diagnosis are supraventricular tachycardia (SVT) with aberrant conduction and bundle branch block (BBB)
Serum electrolytes As electrolyte disturbances commonly cause VT, it's important to screen for electrolyte abnormalities. Hypokalemia, hypomagnesemia, and hypocalcemia might cause VT or torsades de pointes. Serum electrolytes
As electrolyte disturbances commonly cause VT, it's important to screen for electrolyte abnormalities. Hypokalemia, hypomagnesemia, and hypocalcemia might cause VT or torsades de pointes.
Serum drug levels and toxicology screen Overdose of Digoxin, Tri-cyclic antidepressants, cocaine drug levels as these may cause VT Serum drug levels and toxicology screen
Overdose of Digoxin, Tri-cyclic antidepressants, cocaine drug levels as these may cause VT
Serum cardiac markers Myocardial ischemia or infarction can lead to VT, therefore serum cardiac markers are measured. Serum cardiac markers
Myocardial ischemia or infarction can lead to VT, therefore serum cardiac markers are measured.
Echocardiography This is done to diagnose the underlying disease which could be hypertrophic, dilated, or right ventricular cardiomyopathy, segmental hypokinesia due to myocardial infarction Echocardiography
This is done to diagnose the underlying disease which could be hypertrophic, dilated, or right ventricular cardiomyopathy, segmental hypokinesia due to myocardial infarction
Cardiac imaging studies When echocardiography results are inconclusive, to detect structural heart diseases this is done. Cardiac imaging studies
When echocardiography results are inconclusive, to detect structural heart diseases this is done.
Monitoring devices Halter monitoring, implantation of a loop recorder are monitoring devices used to assess patients with history of syncope but when the resting ECG is normal Monitoring devices
Halter monitoring, implantation of a loop recorder are monitoring devices used to assess patients with history of syncope but when the resting ECG is normal
Myocardial biopsy This could be important to diagnose hypertrophic cardiomyopathy, arrhythmogenic right ventricular disease or sarcoidosis, amyloidosis Myocardial biopsy
This could be important to diagnose hypertrophic cardiomyopathy, arrhythmogenic right ventricular disease or sarcoidosis, amyloidosis
Electrophysiological studies (EPS) When a patient has a history of myocardial infarction, or has clinical symptoms of VT rarely these tests are done. Electrophysiological studies (EPS)
When a patient has a history of myocardial infarction, or has clinical symptoms of VT rarely these tests are done.

Investigations - Management

Fact Explanation
Electrocardiography (ECG) To assess for development of any other life threatening arrhythmias such as ventricular fibrillation, and to see the arrhythmias induced by drug therapy. Electrocardiography (ECG)
To assess for development of any other life threatening arrhythmias such as ventricular fibrillation, and to see the arrhythmias induced by drug therapy.
Echocardiography To assess for ejection fraction, for the possibility of congestive cardiac failure as consequence later Echocardiography
To assess for ejection fraction, for the possibility of congestive cardiac failure as consequence later
Liver function tests To see any amiodarone induced liver damage with long term amiodarone therapy Liver function tests
To see any amiodarone induced liver damage with long term amiodarone therapy
Chest x ray To see any amiodarone induced lung changes with long term amiodarone therapy Chest x ray
To see any amiodarone induced lung changes with long term amiodarone therapy
Thyroid profile To see any amiodarone induced hyper/hypothyroidism with long term amiodarone therapy Thyroid profile
To see any amiodarone induced hyper/hypothyroidism with long term amiodarone therapy
Venography Obstruction of the access vein is a known complication of both permanent pacemaker and implantable cardioverter defibrillation implantation, therefore this could be done prior to implantation. Venography
Obstruction of the access vein is a known complication of both permanent pacemaker and implantable cardioverter defibrillation implantation, therefore this could be done prior to implantation.
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen To assess fitness for anesthesia Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen
To assess fitness for anesthesia
Full blood count To exclude anaemia. Full blood count
To exclude anaemia.
Coagulation studies To exclude any coagulopathy. Coagulation studies
To exclude any coagulopathy.
Genetic testing for familial disorders Long QT syndrome, ARVD, or dilated or hypertrophic cardiomyopathy, Catecholaminergic Polymorphic Ventricular Tachycardia have inherited etiologies therefore, genetic testing is done. Genetic testing for familial disorders
Long QT syndrome, ARVD, or dilated or hypertrophic cardiomyopathy, Catecholaminergic Polymorphic Ventricular Tachycardia have inherited etiologies therefore, genetic testing is done.
Electrocardiography To see any features of long QT syndrome, Brugada syndrome in an asymptomatic patient who has a family history of VT or sudden death Electrocardiography
To see any features of long QT syndrome, Brugada syndrome in an asymptomatic patient who has a family history of VT or sudden death
Echocardiography To carry out screening in families who might be affected with hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy which may lead to VT Echocardiography
To carry out screening in families who might be affected with hypertrophic obstructive cardiomyopathy or dilated cardiomyopathy which may lead to VT
Treadmill testing To see any features of exercise induced long QT syndrome, in an asymptomatic patient who has a family history of VT or sudden death Treadmill testing
To see any features of exercise induced long QT syndrome, in an asymptomatic patient who has a family history of VT or sudden death

Management - Supportive

Fact Explanation
Acute management of ventricular tachycardia in an unstable patient. Synchronized direct current (DC) cardioversion is used in patients with unstable monomorphic VT and unstable polymorphic VT is treated with immediate defibrillation. Acute management of ventricular tachycardia in an unstable patient.
Synchronized direct current (DC) cardioversion is used in patients with unstable monomorphic VT and unstable polymorphic VT is treated with immediate defibrillation.
Acute management with drugs in a stable patient Intravenous (IV) procainamide, sotalol, Lidocaine is used in a stable patient Acute management with drugs in a stable patient
Intravenous (IV) procainamide, sotalol, Lidocaine is used in a stable patient
Correction of electrolyte abnormalities hypokalemia or hypomagnesemia from diuretic use should be corrected first Correction of electrolyte abnormalities
hypokalemia or hypomagnesemia from diuretic use should be corrected first
Correction of drug toxicity Treatment with anti-digitalis antibody is required if Digitalis toxicity is suspected Correction of drug toxicity
Treatment with anti-digitalis antibody is required if Digitalis toxicity is suspected
Dietary management low-cholesterol diets, low-salt diets, or both are recommended for patients with VT and caffeine which is a stimulant is also helpful. Dietary management
low-cholesterol diets, low-salt diets, or both are recommended for patients with VT and caffeine which is a stimulant is also helpful.
Activity Increased sympathetic tone during strenuous physical exertion can stimulate a VT. Therefore it's better avoided Activity
Increased sympathetic tone during strenuous physical exertion can stimulate a VT. Therefore it's better avoided
Patient education patient education regarding nature, course, prognosis of disease, the precautions after starting anti arrhythmic therapy, or ICD implantation is needed. Patient education
patient education regarding nature, course, prognosis of disease, the precautions after starting anti arrhythmic therapy, or ICD implantation is needed.
Patient identification When a patient presents with syncope, cardiac arrest, patient identification with a bracelet/ diagnosis card is helpful for further management Patient identification
When a patient presents with syncope, cardiac arrest, patient identification with a bracelet/ diagnosis card is helpful for further management

Management - Specific

Fact Explanation
Anti arrhythmic drug therapy ACC/AHA/ESC guidelines recommend combination of amiodarone and beta blockers when symptoms do not respond to beta blocker or when there's myocardial infarction resulting in ventricular dysfunction. In patients with heart failure beta receptor–blocking drugs (metoprolol, carvedilol, and bisoprolol), Angiotensin-converting enzyme inhibitors (ACEI), Aldosterone antagonists are used. Anti arrhythmic drug therapy
ACC/AHA/ESC guidelines recommend combination of amiodarone and beta blockers when symptoms do not respond to beta blocker or when there's myocardial infarction resulting in ventricular dysfunction. In patients with heart failure beta receptor–blocking drugs (metoprolol, carvedilol, and bisoprolol), Angiotensin-converting enzyme inhibitors (ACEI), Aldosterone antagonists are used.
Radiofrequency catheter ablation Cardiomyopathy, bundle-branch block, and and myocardial infarction causing a dysfunctional ventricles benefit from this Radiofrequency catheter ablation
Cardiomyopathy, bundle-branch block, and and myocardial infarction causing a dysfunctional ventricles benefit from this
Implantable cardioverter defibrillator implantation When a patient has hemodynamically unstable VT, unexplained syncope, familial sudden death syndromes ICD implantation may be beneficial. Implantable cardioverter defibrillator implantation
When a patient has hemodynamically unstable VT, unexplained syncope, familial sudden death syndromes ICD implantation may be beneficial.

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