ECG findings for sustained ventricular tachycardia (VT) include wide QRS complex (duration >120 milliseconds) at a rate greater than 100 bpm.
Patients may have a normal cardiac output or may be haemodynamically compromised during episodes of VT. Presence or absence of symptoms does not reliably differentiate VT from supraventricular tachycardia.
Torsades de pointes is a polymorphic VT with a characteristic twisting morphology occurring in the setting of QT interval prolongation.
Sustained VT is usually observed in ischaemic and non-ischaemic cardiomyopathy, but idiopathic VT may also be observed in patients without structural heart disease.
Among patients with prior myocardial infarction or non-ischaemic cardiomyopathy, VT is usually due to re-entry involving regions of slowed conduction adjacent to scar.
Due to the unpredictable and life-threatening nature of most aetiologies of sustained VT, prophylactic implantable cardioverter defibrillator implantation is recommended in high-risk patients.
Sustained VT is a ventricular rhythm faster than 100 bpm typically lasting at least 30 seconds or requiring termination earlier due to haemodynamic instability. VT is defined as a wide complex tachycardia (QRS 120 milliseconds or greater) that originates from one of the ventricles, and is not due to aberrant conduction (e.g., from bundle branch block), at a rate of 100 bpm or greater. 'Idiopathic' VT occurs in the absence of apparent structural heart disease (e.g., prior myocardial infarction, active ischaemia, cardiomyopathy, valvular disease, arrhythmogenic right ventricular cardiomyopathy, cardiac sarcoid, left ventricular non-compaction, or other disorders of the myocardium), known channelopathy (e.g., long QT syndrome, Brugada syndrome, catecholaminergic polymorphic VT, short QT syndrome), drug toxicity, or electrolyte imbalance. VT can be described as monomorphic or polymorphic. Torsades de pointes is a polymorphic VT with a characteristic twisting morphology occurring in the setting of QT interval prolongation. Sustained VT often results in hypotension and symptoms of weakness, syncope, or palpitations; however, the arrhythmia may be present in patients who are asymptomatic and normotensive.
History and exam
Key diagnostic factors
- coronary artery disease
- presence of other risk factors
Other diagnostic factors
- weak pulse
- airway compromise
- impaired consciousness
- diminished responsiveness
- chest discomfort
- coronary artery disease
- acute myocardial infarction
- left ventricular systolic dysfunction
- hypertrophic cardiomyopathy
- long QT syndrome
- short QT syndrome
- Brugada syndrome
- sleep-disordered breathing (SDB)
- family history of sudden death
- mental or physical stress
- ventricular pre-excitation
- arrhythmogenic right ventricular cardiomyopathy
- electrolyte imbalance
- drug toxicity
- Chagas disease, and other cardiomyopathies
1st investigations to order
- transthoracic echocardiogram
- troponin I
Investigations to consider
- cardiac catheterisation
- cardiac MRI
- electrophysiological (EP) study
- genetic testing
haemodynamically unstable ventricular tachycardia with a pulse
torsades de pointes
catecholaminergic polymorphic ventricular tachycardia
haemodynamically stable non-idiopathic sustained ventricular tachycardia
haemodynamically stable idiopathic sustained ventricular tachycardia
non-idiopathic: at high risk for ventricular tachycardia or history of sustained ventricular tachycardia/cardiac arrest without identifiable reversible cause
idiopathic ventricular tachycardia
Sei Iwai, MD, FACC, FHRS
Professor of Clinical Medicine
New York Medical College
Section Chief, Cardiac Electrophysiology
Westchester Medical Center Health Network
SI is an author of some references cited in this topic.
Professor Sei Iwai would like to gratefully acknowledge Dr Kenneth Stein and Dr Richard Keating, previous contributors to this topic.
KS declares he is an employee of and shareholder in Boston Scientific, a manufacturer of implantable cardioverter defibrillators and ablation catheters. RK declares that he has no competing interests.
Suneet Mittal, MD
The St. Luke's-Roosevelt Hospital Center
SM declares that he has no competing interests.
Kenneth A. Ellenbogen, MD
Kontos Professor of Cardiology
Medical College of Virginia
KAE declares that he has no competing interests.
Kim Rajappan, MA, MD, MRCP
Consultant Cardiologist and Electrophysiologist
John Radcliffe Hospital
KR declares that she has no competing interests.
- Supraventricular tachycardia with aberrancy
- Supraventricular tachycardia with pre-excitation
- Electrical artefact
- 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death
- European resuscitation council guidelines 2021
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