Abstract P24: Epinephrine Single Bolus Dose for Sustained Ventricular Tachycardia: An Unusual and Effective Pharmacological Overdrive Treatment
Background. Ventricular tachycardia (VT) is a common arrhythmia. When sustained with hemodynamic instability, cardioversion is warranted but need use of analgesic drugs with hypotensive side effects. We reported two cases of VT reduced by single bolus dose of epinephrine.
Cases report. Patient 1: A 47 year-old smoker, with no past medical history was admitted to the emergency care unit because of severe fatigue, palpitation and diaphoresis. The blood pressure (BP) was 125/86 mmHg with heart rate (HR) of 185/mn. ECG showed width complex tachycardia with HR 185/mn. Vereckei algorithm (Eur Heart J 2007, 28:589 – 600) though to prove its ventricular origin. Unsuccessful intravenous perfusion of amiodarone (300 mg per 30 min) led to decrease BP up to 75/46 mmHg with profuse sweating. Because patient was well oriented and anaesthesiologist was not available, we could not perform electrical cardioversion. Epinephrine (1 mg per 30 sec) spontaneously restored sinus rhythm after increasing HR up to 200/mn. BP increased up to 130/84 mmHg. Troponin I was elevated (1.2 ng/ml). Two-D echocardiography found inferior wall akinesia, moderate enlargement of left ventricle with an ejection fraction of 40%. Mild segment occlusion of right coronary artery was dilated with bare-metal stent implantation. Patient 2: A 64 year-old patient with previous MI and PCI was admitted in intensive cardiac unit for sustained VT. Implantable cardioverter-defibrillator (ICD) was implanted because of low EF (30%) and recurrent VT. Patient was well oriented with a normal pulse. Amiodarone (300 mg per 30 min) failed to reduce the VT. One single bolus dose of epinephrine (0.7 mg per 30 sec) increased HR to 182/mn and restored sinus rhythm spontaneously. Troponin I was increased (0.9 ng/ml). Coronarography was subnormal.
Discussion. Current guidelines recommend antiarrhythmic drugs and electrical cardioversion for VT. Their side effects, including hypotension, and need of anaesthesiologist complicate the management. Pharmacological overdrive was effective in both cases.
In conclusion, epinephrine could be an effective alternative for treatment of ventricular tachycardia even in acute coronary syndrome. Prospective controlled trials studying its cost-effectiveness are recommended.