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Termination can be achieved with electrical cardioversion, antiarrhythmic medications, or pacing techniques. All anti-arrhythmic drugs (AADs) may lead to hypotension, but the individual risk of anaesthesia/sedation required for cardioversion also needs to be considered. For pharmacological termination of a haemodynamically tolerated VT of unknown aetiology, intravenous procainamide or amiodarone can be used. In the PROCAMIO trial,303 procainamide therapy was associated with a higher proportion of tachycardia termination and fewer major cardiac adverse events than amiodarone. Intravenous procainamide should not be used in patients with severe heart failure, acute MI, and end-stage renal disease. Administration of other AADs (ajmaline, sotalol, and flecainide)304,305 may be considered in patients without significant heart disease, but the risk of adverse events should be carefully weighed. Availability of AADs has to be taken into account, e.g. procainamide is not available in many European countries. In patients with an ICD, manual overdrive pacing may terminate those VTs with a cycle length under the programmed ICD detection rate. In case of a known idiopathic VT (Figure 4), treatment with beta-blockers (for RVOT VT)306 or verapamil (for fascicular VT)307 is recommended for acute conversion. Although verapamil may terminate other types of idiopathic VT,307

important adverse effects such as severe hypotension may occur. If the VT aetiology is uncertain, intravenous administration of verapamil is not recommended.308,309 A comprehensive evaluation of patients presenting with SMVT is mandatory if the underlying cardiac disease is unknown or disease progression is suspected (Section 5.2.2, scenario 2).

6.1.3 Management of electrical storm and incessant

ventricular tachycardia An electrical storm is common in ICD patients and has been defined as three or more episodes of sustained VA occurring within 24 h,

00:00

mm:ss

00:30 01:00 01:30 02:00 02:30 03:00 03:30 04:00 04:30 05:00 05:30 06:00 06:30 07:00 07:30 08:00 08:30 09:00 Repetitive runs of VT

Figure 10 Repetitive runs of ventricular tachycardia interrupted by occasional sinus beats. VT, ventricular tachycardia. Downloaded from academic.oup.com/eurheartj/article/43/40/3997/6675633 by guest on 07 October 2026