Chapter 13: Ventricular Tachycardia

Introduction

The magnitude of ventricular tachycardia (VT), one of the most common health problems encountered in clinical practice, can best be appreciated in terms of its various clinical manifestations, which include ventricular fibrillation (sudden cardiac death [SCD]), syncope or near-syncope, and wide QRS tachycardia.

The most serious is its degeneration into ventricular fibrillation, producing cardiac arrest and SCD that accounts for 200,000 deaths a year. The second most serious clinical presentation is syncope. Although the overall prevalence of VT-related syncope is unclear, it is estimated to be frequent because inducible VT (via electrical stimulation) is the most common arrhythmia detected in patients with unexplained syncope. A high prevalence of SCD (> 20% incidence within the ensuing 12 months) is noted in patients with syncope from cardiovascular causes, suggesting that undiagnosed VT may be an underlying cause of sudden death in patients with unexplained syncope. The third most significant clinical manifestation of VT is a wide QRS complex tachycardia that is often hemodynamically well tolerated.

Diagnostic Issues

1. Underdiagnosis

VT as a cause of morbidity and mortality is grossly underdiagnosed, potentially leading to mismanagement. This may be particularly true when the clinical presentation is unexplained syncope because no concomitant electrocardiographic (ECG) documentation is available. In the case of cardiac arrest or SCD, acute myocardial infarction rather than an arrhythmic problem is often assumed to be responsible. Most persons who have suffered sudden death have no evidence of acute myocardial necrosis, even though the episode often occurs in patients with underlying coronary artery disease. Managing the underlying coronary artery disease with no regard to treating the concomitant VT is inadequate.

2. Misdiagnosis

When hemodynamically stable VT is recorded on the surface ECG, it is often misdiagnosed as supraventricular tachycardia (SVT) with aberrant conduction. Any subsequent management is therefore directed toward SVT. Although the exact logic for this line of thinking is unclear, the main reason may be that the hemodynamic stability is associated with the broad QRS rhythm and thus the erroneous belief that the problem cannot be VT.

The clinical presentation of VT depends on many factors, including rate, ventricular function, presence of concomitant coronary artery disease, the presence or absence of cardioactive drugs, and even the patient’s posture at the time of onset. Hemodynamic tolerance of VT can, therefore, vary considerably in different situations; at times, it can vary in the same patient, and it is prudent not to exclude the diagnosis of VT on the basis of hemodynamic tolerance alone. It must be understood ...