Sustained Monomorphic VT Without Structural Heart Disease — Next Step After IV Antiarrhythmic Drug Failure

Clinical scenario

Sustained monomorphic ventricular tachycardia in a patient without significant structural heart disease, haemodynamically tolerated — and initial intravenous antiarrhythmic drug therapy has not achieved termination of the arrhythmia.

Goal: termination of VT with restoration of sinus rhythm

Previous line — antiarrhythmic therapy did not reach the goal

Treatment with intravenous antiarrhythmic agents — which may include flecainide, ajmaline, sotalol, procainamide, or amiodarone — failed to terminate ventricular tachycardia and convert to sinus rhythm. This failure triggers escalation to the next structured step.

Next-step approach (partial overview)

The protocol moves to a direct electrical intervention — with the risk of anaesthesia and sedation being the key factor that determines when and how it is applied. The complete decision algorithm, prerequisites, and procedural details are in the full protocol.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehac262

DC cardioversion is recommended as the first-line treatment for patients presenting with tolerated SMVT provided that the anaesthetic/sedation risk is low.

In patients presenting with a haemodynamically tolerated SMVT in the absence of significant SHD, flecainide, ajmaline, or sotalol may be considered.

In patients presenting with a haemodynamically tolerated SMVT in the absence of an established diagnosis, intravenous amiodarone may be considered.

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