CLINICAL MANAGEMENT GUIDELINE

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📋 For Healthcare Professionals Only

Format: Action-oriented, clinically focused

Emphasis: Recognition | ECG Diagnosis | Acute Management | Long-term Treatment

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🔰 SYMBOL LEGEND

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SECTION 1: INITIAL APPROACH TO TACHYCARDIA

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1.1 FIRST QUESTION: IS THE PATIENT STABLE OR UNSTABLE?

🚨 UNSTABLE = IMMEDIATE DC CARDIOVERSION

Unstable Features

Hypotension (SBP < 90 mmHg)

Altered consciousness

Severe chest pain / Ongoing ischemia

Acute pulmonary edema

Signs of shock

If ANY Unstable Feature Present

Action

Synchronized DC Cardioversion

Do NOT delay for investigations

Sedate if conscious (Midazolam 1-2 mg IV)

Unsynchronized shock if pulseless or cannot synchronize

DC Cardioversion Energies

Arrhythmia	Energy (Biphasic)
Narrow complex regular	50-100 J
Narrow complex irregular (AF)	120-200 J
Wide complex regular	100-200 J
VF / Pulseless VT	120-200 J (unsynchronized)

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1.2 SECOND QUESTION: NARROW OR WIDE QRS?

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1.3 THIRD QUESTION: REGULAR OR IRREGULAR?

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SECTION 2: NARROW COMPLEX TACHYCARDIAS

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2.1 DIFFERENTIAL DIAGNOSIS

Regular Narrow Complex Tachycardia

Arrhythmia	Rate	P Waves	Key Features
Sinus tachycardia	100-150	Before QRS, Normal	Gradual onset/offset; Cause identifiable
AVNRT	150-250	Buried or Pseudo-R’ (V1)	Sudden onset/offset; Common
AVRT (Orthodromic)	150-250	After QRS (RP > 70ms)	Young; May have WPW on baseline ECG
Atrial flutter	Atrial 250-350; Ventricular depends on block	Sawtooth (II, III, aVF)	Often 2:1 block (150 bpm)
Atrial tachycardia	100-250	Before QRS, Abnormal morphology	P wave different from sinus

Irregular Narrow Complex Tachycardia

Arrhythmia	Key Features
Atrial fibrillation	No P waves; Irregularly irregular; Fibrillatory baseline
Atrial flutter with variable block	Flutter waves; Variable ventricular response
MAT	≥3 different P wave morphologies; Irregular

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2.2 ECG DIAGNOSIS OF NARROW COMPLEX TACHYCARDIA

Step 1: Is it Sinus Tachycardia?

Feature	Sinus Tachycardia
Rate	Usually < 150 (rarely > 180)
P waves	Upright in I, II; Inverted in aVR
Onset/Offset	Gradual
Cause	Identifiable (Pain, Fever, Hypovolemia, Anxiety)

📌 If clearly sinus tachycardia → Treat the underlying cause, NOT the tachycardia

Step 2: Look at Regularity

Regularity	Consider
Regularly regular	AVNRT, AVRT, Atrial flutter (fixed block), AT
Irregularly irregular	AF, MAT, Atrial flutter (variable block)

Step 3: Look for P Waves and RP Interval

P Wave Location	RP Interval	Diagnosis
No visible P waves	-	AVNRT (typical), AF
Pseudo-R’ in V1 / Pseudo-S in inferior leads	Very short	AVNRT
P after QRS	Short (< 70 ms)	AVNRT
P after QRS	Long (> 70 ms)	AVRT, Atypical AVNRT, AT
P before QRS	Long RP	AT, Atypical AVNRT, PJRT
Sawtooth in II, III, aVF	-	Atrial flutter
Multiple P morphologies	-	MAT

AVNRT vs AVRT Summary

Feature	AVNRT	Orthodromic AVRT
P wave	Buried / Pseudo-R’ V1	After QRS, Inverted in inferior leads
RP interval	< 70 ms	> 70 ms
Baseline ECG	Normal	May show delta wave (WPW)
Age	Any; More common middle-aged women	Often younger

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2.3 ACUTE MANAGEMENT: REGULAR NARROW COMPLEX TACHYCARDIA

If Stable: Stepwise Approach

STABLE REGULAR NARROW COMPLEX TACHYCARDIA

│

▼

STEP 1: VAGAL MANEUVERS

────────────────────────

• Modified Valsalva (REVERT technique)

• Carotid sinus massage (if no contraindication)

│

▼

TERMINATED?

│

┌─────────┴─────────┐

│ │

YES NO

│ │

▼ ▼

Likely AVNRT/ STEP 2: ADENOSINE

AVRT ───────────────────

Document rhythm 6 mg IV rapid push

Consider EP referral ↓ flush immediately

│

▼

RESPONSE?

│

┌────────────────────┼────────────────────┐

│ │ │

▼ ▼ ▼

TERMINATES REVEALS P WAVES NO EFFECT

Sinus rhythm Continues (rare)

│ │ │

▼ ▼ ▼

AVNRT/AVRT AT or Flutter Repeat 12 mg

│ If still no effect:

▼ Consider AT, VT

Treat accordingly

Vagal Maneuvers – Techniques

Technique	Method	Success
Modified Valsalva (REVERT)	Blow into 10 mL syringe for 15 sec → Immediately lie flat with legs raised 45° for 15 sec	43%
Standard Valsalva	Blow into 10 mL syringe for 15 sec while seated	17%
Carotid sinus massage	Firm pressure over carotid bifurcation for 5-10 sec; One side at a time	Variable
Ice to face	Ice-cold water or ice pack to face (triggers diving reflex)	Variable

❌ Carotid Massage Contraindications

Carotid bruit

Recent stroke/TIA

History of VT

Adenosine Administration

Parameter	Details
💊 Adenosine	6 mg IV rapid push → Flush with 20 mL saline
Site	Large vein (antecubital); As proximal as possible
Technique	Rapid push; Follow immediately with flush; Arm elevated
If no effect	12 mg → 12 mg (can repeat once)
Onset	Seconds
Duration	6-10 seconds

Adenosine: What the Response Tells You

Response	Diagnosis	Next Step
Terminates → Sinus rhythm	AVNRT or AVRT	Diagnosis confirmed; Consider long-term management
Transient AV block → P waves/Flutter waves revealed → Resumes	Atrial tachycardia or Atrial flutter	Treat with rate/rhythm control
Terminates → Different P wave → Resumes	Adenosine-sensitive AT (minority)	Consider beta-blocker or CCB
Irregularly irregular during AV block	Atrial fibrillation	Treat as AF
No effect	? AT, ? VT (if actually wide)	Re-evaluate; Try other agents

❌ Adenosine Contraindications

Contraindication

Pre-excited AF (WPW with AF) – Can cause VF

Severe asthma/COPD (relative – can use with caution)

Heart transplant (increased sensitivity – use 3 mg)

On Dipyridamole (increased sensitivity)

On Theophylline (reduced effect – higher dose needed)

If Adenosine Fails or Contraindicated

Option	Dose	Notes
💊 Verapamil	2.5-5 mg IV over 2 min; Repeat 5-10 mg after 15-30 min	❌ Avoid in HFrEF, Hypotension, WPW
💊 Diltiazem	15-20 mg (0.25 mg/kg) IV over 2 min	❌ Avoid in HFrEF, Hypotension, WPW
💊 Metoprolol	2.5-5 mg IV over 2 min; Repeat q5 min (max 15 mg)	⚠️ Caution in asthma
💊 Esmolol	500 μg/kg bolus → 50-200 μg/kg/min infusion	Short-acting; Titratable
DC Cardioversion	Synchronized 50-100 J	If refractory or hemodynamically deteriorating

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2.4 SPECIFIC ARRHYTHMIA MANAGEMENT

AVNRT

Phase	Management
Acute termination	Vagal maneuvers → Adenosine → Verapamil/Diltiazem/Beta-blocker → DC cardioversion
Recurrence prevention	Catheter ablation (✅ First-line; >95% success)
If ablation declined	Pill-in-pocket (Diltiazem + Propranolol) OR Daily beta-blocker/CCB

AVRT (Orthodromic)

Phase	Management
Acute termination	Same as AVNRT
Long-term	Catheter ablation (✅ First-line; >95% success)
If WPW on baseline ECG	Ablation recommended (risk of pre-excited AF)

Atrial Flutter

Phase	Management
Acute (Unstable)	DC cardioversion 50-100 J
Acute (Stable)	Rate control (Beta-blocker, Diltiazem, Digoxin) OR Cardioversion
Anticoagulation	Same as AF (CHA₂DS₂-VASc score)
Long-term	Catheter ablation (CTI ablation; ✅ First-line; >95% success)

Atrial Tachycardia

Phase	Management
Acute	Rate control (Beta-blocker, CCB) first
Acute rhythm control	Flecainide, Propafenone (no structural HD); Amiodarone (structural HD)
Adenosine	🔍 Diagnostic (reveals P waves); May terminate adenosine-sensitive AT (minority)
Long-term	Catheter ablation (85-95% success for focal AT)
If ablation not available/declined	Antiarrhythmic drugs

📌 Adenosine in AT

Primary role: DIAGNOSTIC – Reveals P wave morphology

Does NOT terminate most ATs

Exception: Adenosine-sensitive ATs (triggered activity) may terminate

MAT (Multifocal Atrial Tachycardia)

Management

Treat underlying cause (COPD, Hypoxia, Electrolytes, Theophylline)

Rate control: Verapamil or Diltiazem (preferred if COPD)

💊 Magnesium 2 g IV (may help)

Metoprolol (with caution if COPD)

❌ DC cardioversion ineffective

❌ Adenosine ineffective

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2.5 ATRIAL FIBRILLATION – ACUTE MANAGEMENT

Initial Assessment

Assess

Hemodynamic stability

Duration (< 48 hours vs ≥ 48 hours vs Unknown)

Symptoms

Underlying cause (Sepsis, Thyroid, PE, Post-op)

Unstable AF

Management

DC Cardioversion (synchronized 120-200 J biphasic)

Proceed regardless of anticoagulation status

Stable AF – Rate Control vs Rhythm Control

Approach	When to Use
Rate control	Older patients; Minimal symptoms; Long-standing AF; Failed rhythm control
Rhythm control	Symptomatic; Recent onset; Younger; First episode; Patient preference

Rate Control

Target	Drugs
Lenient: < 110 bpm at rest	Acceptable for most
Strict: < 80 bpm at rest	If still symptomatic

Patient Profile	Drug Choice
No HFrEF	Beta-blocker OR Diltiazem/Verapamil
HFrEF	Beta-blocker (Carvedilol, Bisoprolol, Metoprolol) + Digoxin
Sedentary/Elderly	Digoxin (if others contraindicated)
COPD	Diltiazem/Verapamil preferred
Hypotension	Digoxin (slower onset)

Drug	IV Dose	Oral Dose
💊 Metoprolol	2.5-5 mg IV q5 min (max 15 mg)	25-100 mg BD
💊 Diltiazem	15-20 mg IV; Infusion 5-15 mg/hr	60-120 mg TDS or SR 120-240 mg OD
💊 Verapamil	2.5-10 mg IV over 2 min	40-120 mg TDS
💊 Digoxin	0.5 mg IV; Then 0.25 mg q6h × 2	0.125-0.25 mg OD

Rhythm Control – Cardioversion

Duration	Approach
< 48 hours	Cardiovert (initiate anticoagulation)
≥ 48 hours or Unknown	Anticoagulate × 3 weeks THEN Cardiovert OR TOE to exclude LAA thrombus → Cardiovert
Post-cardioversion	Anticoagulation × minimum 4 weeks (lifelong based on CHA₂DS₂-VASc)

Pharmacological Cardioversion

Drug	Efficacy	Notes
💊 Flecainide	70-90% (if < 24h)	2 mg/kg IV over 10 min (max 150 mg); ❌ Avoid structural HD
💊 Propafenone	70-90%	2 mg/kg IV over 10 min; ❌ Avoid structural HD
💊 Amiodarone	40-60%	5-7 mg/kg over 1-2 hr; ✅ Safe in structural HD
💊 Ibutilide	50-70%	1 mg IV over 10 min; ⚠️ Risk of Torsades

Pill-in-Pocket (Outpatient Cardioversion)

Criteria

Infrequent, symptomatic AF

No structural heart disease

Previously tested in hospital

SBP > 100 mmHg; HR > 70 bpm

Regimen

Flecainide 200-300 mg PO OR Propafenone 450-600 mg PO

With beta-blocker (to prevent rapid atrial flutter)

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2.6 ATRIAL FIBRILLATION – ANTICOAGULATION

CHA₂DS₂-VASc Score

Risk Factor	Points
C – CHF / LV dysfunction	1
H – Hypertension	1
A₂ – Age ≥ 75	2
D – Diabetes	1
S₂ – Stroke/TIA/Thromboembolism	2
V – Vascular disease (MI, PAD, Aortic plaque)	1
A – Age 65-74	1
Sc – Sex category (Female)	1

Anticoagulation Decision

Score	Men	Women	Recommendation
0	0	1	No anticoagulation
1	1	2	Consider anticoagulation
≥ 2	≥ 2	≥ 3	✅ Anticoagulate

Anticoagulation Options

Drug	Dose	Notes
💊 Dabigatran	150 mg BD (110 mg BD if age ≥ 80 or high bleeding risk)	❌ Avoid if CrCl < 30
💊 Rivaroxaban	20 mg OD with food (15 mg if CrCl 15-50)
💊 Apixaban	5 mg BD (2.5 mg BD if ≥ 2 of: Age ≥ 80, Weight ≤ 60 kg, Cr ≥ 1.5)	✅ Preferred if CKD
💊 Edoxaban	60 mg OD (30 mg if CrCl 15-50, Weight ≤ 60 kg, or on P-gp inhibitor)
💊 Warfarin	Dose to INR 2-3	For mechanical valves, Moderate-severe MS

📌 DOAC vs Warfarin

DOACs preferred over Warfarin in most patients

Warfarin required: Mechanical heart valves, Moderate-severe mitral stenosis

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2.7 PRE-EXCITED AF (WPW WITH AF)

Recognition

ECG Features

Irregularly irregular

Very fast (can be > 200-300 bpm)

Wide QRS (varying width)

Delta waves visible

Different from typical AF with BBB

🚨 DANGER

❌ AVOID These Drugs

Adenosine

Digoxin

Verapamil

Diltiazem

Beta-blockers (IV)

Why?

These block AV node → More conduction through accessory pathway → Faster ventricular rate → VF

Management

Unstable	DC Cardioversion (unsynchronized if very fast/hemodynamically compromised)
Stable	💊 Procainamide 15-17 mg/kg IV over 30-60 min OR 💊 Ibutilide OR 💊 Amiodarone (less preferred but acceptable)
Definitive	Catheter ablation of accessory pathway

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SECTION 3: WIDE COMPLEX TACHYCARDIAS

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3.1 APPROACH

📌 Assume wide complex tachycardia is VT until proven otherwise

Treating VT as SVT is dangerous; Treating SVT as VT is safe

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3.2 DIFFERENTIAL DIAGNOSIS

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3.3 ECG DIFFERENTIATION: VT VS SVT WITH ABERRANCY

Features Favoring VT

Feature	Description
AV dissociation	P waves unrelated to QRS (look carefully)
Capture beats	Narrow QRS during wide complex (sinus captures ventricle)
Fusion beats	Intermediate morphology (sinus + VT)
QRS > 160 ms	Very wide QRS favors VT
Northwest axis	Extreme axis deviation
Concordance in precordial leads	All positive or all negative V1-V6
RS > 100 ms in any precordial lead	Brugada sign
Absence of RS complex in all precordial leads
History of structural heart disease	Strong predictor of VT
Age > 35	More likely VT
Hemodynamic stability does NOT exclude VT	VT can be stable

Morphological Criteria

Lead	VT Favored	SVT with Aberrancy Favored
RBBB pattern (V1 positive)	Monophasic R, qR, or Rs in V1	rSR’ (classic RBBB)
	R/S < 1 in V6	R/S > 1 in V6
LBBB pattern (V1 negative)	R wave > 30 ms in V1/V2	No R wave or R < 30 ms
	Notched S downstroke	Smooth S downstroke
	QS or rS in V6	No Q wave in V6

Brugada Algorithm (Simplified)

Step	Finding	Diagnosis
1	Absence of RS complex in all precordial leads	→ VT
2	RS interval > 100 ms in any precordial lead	→ VT
3	AV dissociation	→ VT
4	Morphology criteria for VT in V1/V2 AND V6	→ VT
5	None of the above	→ SVT with aberrancy

When in Doubt

📌 Rule

Treat as VT

VT is far more common

Treating VT as SVT can be fatal

Treating SVT as VT is usually well-tolerated

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3.4 ACUTE MANAGEMENT: WIDE COMPLEX TACHYCARDIA

Algorithm

WIDE COMPLEX TACHYCARDIA

│

▼

IS PATIENT STABLE?

│

┌─────────┴─────────┐

│ │

▼ ▼

UNSTABLE STABLE

│ │

▼ ▼

🚨 DC CARDIOVERSION IS IT REGULAR?

100-200 J synchronized │

(Unsync if VF/pulseless) ┌───┴───┐

│ │

▼ ▼

REGULAR IRREGULAR

│ │

▼ ▼

ASSUME VT PRE-EXCITED AF

│ vs AF with BBB

│ vs Polymorphic VT

│ │

▼ ▼

TREAT AS VT (See specific

management)

Stable Regular Wide Complex Tachycardia (Probable VT)

Step	Action
1	12-lead ECG – Analyze for VT vs SVT features
2	If clearly SVT with BBB → Treat as narrow complex
3	If VT or uncertain → Treat as VT

Medical Treatment of Stable VT

Drug	Dose	Notes
💊 Amiodarone	150 mg IV over 10 min → 1 mg/min × 6 hr → 0.5 mg/min × 18 hr	✅ First-line; Safe in structural HD
💊 Procainamide	15-17 mg/kg IV over 30-60 min (max 50 mg/min) → 1-4 mg/min	⚠️ Avoid in HFrEF; Watch QT and BP
💊 Lidocaine	1-1.5 mg/kg bolus → 1-4 mg/min	Less effective than amiodarone; Useful in ischemia

If Medical Therapy Fails

DC Cardioversion (synchronized 100-200 J)

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3.5 SPECIFIC VENTRICULAR ARRHYTHMIAS

Monomorphic VT

Feature	Details
Definition	Regular, Uniform QRS morphology
Cause	Usually structural heart disease (Ischemic, DCM, HCM, ARVC, Sarcoid)
Acute	DC cardioversion if unstable; Amiodarone/Procainamide if stable
Long-term	ICD (secondary prevention); Treat underlying cause; Catheter ablation if recurrent

Polymorphic VT

Subtype	QTc	Management
Normal QT Polymorphic VT	Normal	Treat ischemia aggressively; Revascularization; Beta-blocker; Amiodarone
Torsades de Pointes	Prolonged (> 500 ms)	See Section 3.6

NSVT (Non-Sustained VT)

Definition	≥ 3 beats at > 100 bpm, lasting < 30 seconds
In normal heart	Usually benign; Reassure
In structural HD	Risk marker; May need ICD evaluation
Post-MI with LVEF ≤ 35%	ICD indicated

VF (Ventricular Fibrillation)

Management

Immediate defibrillation 120-200 J biphasic (unsynchronized)

CPR; ACLS protocol

Adrenaline 1 mg IV q3-5 min

Amiodarone 300 mg IV (then 150 mg) for refractory VF

Post-arrest: Identify and treat cause; Consider ICD

Idiopathic VT (Structurally Normal Heart)

Type	Features	Treatment
RVOT VT	LBBB morphology; Inferior axis; Exercise-induced	Adenosine-sensitive; Beta-blocker; Ablation (>90% success)
Fascicular (LV) VT	RBBB + LAD; Young males	Verapamil-sensitive; Ablation
Idiopathic LV VT	RBBB morphology	Verapamil or beta-blocker; Ablation

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3.6 TORSADES DE POINTES

Recognition

Features

Polymorphic VT with ”twisting“ QRS around baseline

Prolonged QTc on baseline ECG

Often preceded by ”short-long-short“ sequence

May degenerate to VF

Causes of QT Prolongation

Drugs	Other
Antiarrhythmics (Sotalol, Amiodarone, Procainamide, Quinidine)	Hypokalemia
Antipsychotics	Hypomagnesemia
Antibiotics (Macrolides, Fluoroquinolones)	Hypocalcemia
Antiemetics (Ondansetron, Metoclopramide)	Bradycardia
Antidepressants (TCAs, some SSRIs)	Congenital Long QT syndrome
Check: CredibleMeds.org	Hypothermia

Management

Step	Action
1	Stop ALL QT-prolonging drugs
2	💊 Magnesium 2 g IV over 2-10 min (even if Mg normal)
3	Correct potassium to > 4.5 mEq/L
4	Increase heart rate (shortens QT):
	• 💊 Isoprenaline 2-10 μg/min IV infusion
	• OR Temporary pacing at 90-110 bpm
5	Defibrillation if VF or pulseless

❌ AVOID in Torsades

Amiodarone (prolongs QT)

Sotalol (prolongs QT)

Procainamide (prolongs QT)

Any QT-prolonging drug

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3.7 VT STORM

Definition

Criteria

≥ 3 episodes of sustained VT or VF within 24 hours

Requiring intervention (cardioversion, defibrillation, or antiarrhythmic)

Management

Priority	Action
1	Sedation (reduces catecholamine surge)
2	💊 Amiodarone IV (load + infusion)
3	💊 Beta-blocker (even if HFrEF – cautiously)
4	Correct electrolytes: K+ > 4.5 mEq/L; Mg2+ > 2 mEq/L
5	Treat ischemia if present
6	Emergency catheter ablation if refractory
7	Consider: Stellate ganglion block; ECMO; Overdrive pacing

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SECTION 4: CHANNELOPATHIES

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4.1 LONG QT SYNDROME (LQTS)

Diagnosis

Criteria

QTc > 480 ms (≥ 500 ms high-risk)

QTc 460-480 ms with syncope or family history

Schwartz score ≥ 3.5

Genetic testing positive

QTc Calculation

Formula (Bazett)

QTc = QT / √RR (in seconds)

Normal: < 450 ms (men), < 460 ms (women)

Management by Type

Type	Trigger	Treatment
LQT1	Exercise (especially swimming)	Beta-blocker (most effective); Avoid competitive sports
LQT2	Auditory stimuli, Emotion	Beta-blocker; Avoid sudden loud noises
LQT3	Rest, Sleep	Mexiletine; Consider ICD

General Management

Intervention

✅ Beta-blocker (Nadolol or Propranolol preferred)

✅ Avoid QT-prolonging drugs

✅ Correct electrolytes

✅ ICD if: Cardiac arrest survivor, Syncope on beta-blocker, QTc > 500 ms with risk factors

✅ Screen family members

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4.2 BRUGADA SYNDROME

Diagnosis

Criteria

Type 1 Brugada ECG pattern (Coved ST elevation ≥ 2 mm in V1-V3)

Spontaneous OR Drug-induced (Ajmaline/Flecainide challenge)

ECG Patterns

Type	Pattern	Significance
Type 1	Coved ST elevation ≥ 2 mm → T wave inversion	Diagnostic
Type 2	Saddleback ST ≥ 2 mm	Suggestive; May need drug challenge
Type 3	Saddleback < 1 mm or Coved < 2 mm	Non-diagnostic

Risk Stratification

High Risk	Lower Risk
Prior cardiac arrest	Asymptomatic
Spontaneous Type 1 + Syncope	Drug-induced Type 1 only
Spontaneous Type 1 + Inducible VF on EPS (controversial)	No symptoms

Management

Intervention	Indication
ICD	✅ Cardiac arrest survivor; ✅ Spontaneous Type 1 + Syncope
Quinidine	ICD not available; Multiple shocks; Consider
Catheter ablation	Recurrent VT/VF; VT storm
Avoid	Drugs on www.brugadadrugs.org; Fever (treat aggressively); Excessive alcohol
Isoproterenol	For VF storm (increases HR, suppresses ST)

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4.3 CPVT (Catecholaminergic Polymorphic VT)

Features

Feature

Exercise or emotion-triggered bidirectional/polymorphic VT

Normal resting ECG and QTc

Structurally normal heart

RYR2 mutation most common

Usually presents in childhood/adolescence

Diagnosis

Test

Exercise stress test (provokes arrhythmia)

Adrenaline infusion

Genetic testing

Management

Intervention

💊 Beta-blocker (Nadolol preferred; Maximum tolerated dose)

💊 Flecainide (add if beta-blocker insufficient)

ICD if cardiac arrest survivor or breakthrough events on meds

❌ Avoid competitive sports, Strenuous exercise, Catecholamines

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4.4 ARVC (Arrhythmogenic Right Ventricular Cardiomyopathy)

Features

Feature

Fibrofatty replacement of RV (± LV)

VT with LBBB morphology (arises from RV)

Epsilon waves, T-wave inversion V1-V3

RV dysfunction on imaging

Familial (desmosomal mutations)

Diagnosis

2010 Task Force Criteria

Major and minor criteria across:

Structure (RV dysfunction), Tissue (fibrofatty), ECG, Arrhythmia, Family history

Definite: 2 Major, OR 1 Major + 2 Minor, OR 4 Minor

Management

Intervention

❌ Avoid endurance exercise (worsens disease)

💊 Beta-blocker (Sotalol if tolerated)

💊 Amiodarone (for VT suppression)

ICD if high-risk (sustained VT, Low LVEF, Significant RV dysfunction)

Catheter ablation (often needs epicardial approach)

Family screening

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SECTION 5: DEVICE THERAPY

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5.1 ICD INDICATIONS

Secondary Prevention (Highest Priority)

Indication

Survivors of VF or hemodynamically unstable VT

VT with syncope

VT with LVEF ≤ 40%

Primary Prevention

Indication

Ischemic cardiomyopathy: LVEF ≤ 35% despite ≥ 3 months GDMT, ≥ 40 days post-MI, NYHA II-III

Non-ischemic cardiomyopathy: LVEF ≤ 35% despite ≥ 3 months GDMT, NYHA II-III

HCM: ESC HCM Risk-SCD ≥ 6% at 5 years

ARVC: High-risk features

Channelopathies: High-risk LQTS, Brugada with syncope, CPVT with breakthrough on meds

ICD Not Indicated

Scenario

NYHA Class IV not candidate for transplant/VAD

Incessant VT/VF

Life expectancy < 1 year

Reversible cause of VT/VF

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5.2 CATHETER ABLATION INDICATIONS

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SECTION 6: ANTIARRHYTHMIC DRUGS

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6.1 VAUGHAN-WILLIAMS CLASSIFICATION

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6.2 DRUG SELECTION BY ARRHYTHMIA AND SUBSTRATE

SVT (AVNRT, AVRT, AT)

Substrate	Options
No structural HD	Flecainide, Propafenone, Sotalol, Beta-blocker
Structural HD	Beta-blocker, Amiodarone

Atrial Fibrillation

Substrate	Rhythm Control Options
No/Minimal structural HD	Flecainide, Propafenone, Dronedarone, Sotalol
CAD	Sotalol, Dronedarone, Amiodarone
HFrEF	Amiodarone ONLY
LVH (significant)	Amiodarone

Ventricular Arrhythmias

Substrate	Options
Structural HD (Ischemic/DCM)	Amiodarone, Sotalol (with caution)
Idiopathic (RVOT)	Beta-blocker, CCB (verapamil if LV), Flecainide
LQTS	Beta-blocker; Mexiletine for LQT3
Brugada	Quinidine; Avoid Class IC

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6.3 KEY ANTIARRHYTHMIC DRUG PROFILES

💊 Amiodarone

Parameter	Details
Mechanism	Class III (+ I, II, IV effects)
Loading	IV: 150 mg over 10 min → 1 mg/min × 6h → 0.5 mg/min × 18h; PO: 200 mg TDS × 1 week → 200 mg BD × 1 week → 200 mg OD
Maintenance	200 mg OD
Half-life	40-55 days
Efficacy	Most effective AAD for AF and VT
Safe in HFrEF	✅ Yes
Toxicities	Thyroid (hypo/hyper), Pulmonary fibrosis, Hepatic, Corneal deposits, Skin (photosensitivity, blue-gray), Bradycardia, QT prolongation
Monitoring	TFT, LFT, CXR, Eye exam q6-12 months

💊 Sotalol

Parameter	Details
Mechanism	Class III + Non-selective beta-blocker
Dose	80-160 mg BD
Initiation	In-hospital (risk of Torsades)
❌ Avoid	HFrEF, LVH, QTc > 450 ms, CrCl < 40 mL/min, Hypokalemia
Monitoring	QTc, K+, Renal function

💊 Flecainide

Parameter	Details
Mechanism	Class IC (potent Na+ block)
Dose	50-150 mg BD
Use	AF, SVT, CPVT (adjunct)
❌ Contraindicated	Structural heart disease, CAD, HFrEF (CAST trial)
Must combine with	AV nodal blocker (beta-blocker) – prevents 1:1 atrial flutter
Side effects	Proarrhythmia, Dizziness, Visual disturbance

💊 Dronedarone

Parameter	Details
Mechanism	Similar to Amiodarone (no iodine)
Dose	400 mg BD
Use	AF rhythm control
❌ Contraindicated	HFrEF (ANDROMEDA – increased mortality), Permanent AF (PALLAS), Severe HF
Benefit	ATHENA trial – reduced CV hospitalization

💊 Procainamide

Parameter	Details
Mechanism	Class IA
IV Dose	15-17 mg/kg over 30-60 min (max rate 50 mg/min) → 1-4 mg/min infusion
Use	Stable VT, Pre-excited AF
❌ Avoid	HFrEF, QT prolongation
Monitoring	BP, QRS width, QT interval

💊 Lidocaine

Parameter	Details
Mechanism	Class IB
IV Dose	1-1.5 mg/kg bolus → 1-4 mg/min infusion
Use	VT (especially ischemic), VF (refractory)
Less effective than Amiodarone
Side effects	CNS toxicity, Seizures

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6.4 DRUGS TO AVOID IN SPECIFIC SITUATIONS

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SECTION 7: ACUTE DRUG DOSES – QUICK REFERENCE

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7.1 SVT / RATE CONTROL

7.2 RHYTHM CONTROL / AF CARDIOVERSION

7.3 VT / VF

7.4 TORSADES DE POINTES

7.5 PRE-EXCITED AF

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SECTION 8: DC CARDIOVERSION ENERGIES

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SECTION 9: SUMMARY ALGORITHMS

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9.1 NARROW COMPLEX TACHYCARDIA

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9.2 WIDE COMPLEX TACHYCARDIA

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9.3 TORSADES DE POINTES

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SECTION 10: PATIENT EDUCATION POINTS

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10.1 SVT / AVNRT / AVRT

10.2 ATRIAL FIBRILLATION

10.3 ICD PATIENTS

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SECTION 11: INDIA PRACTICAL CONSIDERATIONS

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11.1 DRUG AVAILABILITY

11.2 ELECTROPHYSIOLOGY SERVICES

11.3 COST CONSIDERATIONS

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📚 ABBREVIATIONS

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📖 KEY REFERENCES

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Document Version: 2.0

Last Updated: December 2024

For: Healthcare Professionals Only

Key Corrections from Previous Version:

• • Clarified adenosine’s role in atrial tachycardia (primarily diagnostic, NOT therapeutic for most ATs)
  • Added adenosine-sensitive AT as minority exception
  • Reorganized for clinical utility
  • Removed excessive epidemiology
  • Enhanced acute management algorithms

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