Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

no cardiac comorbidity: asymptomatic and ≤10% NSVT/premature ventricular contraction (PVC) burden

1st line – correction of electrolyte abnormality

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ONGOING
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no cardiac comorbidity: asymptomatic and ≤10% NSVT/premature ventricular contraction (PVC) burden
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with electrolyte abnormality
1st line – 

correction of electrolyte abnormality

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

1st line – reassurance + self-monitoring

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ONGOING
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no cardiac comorbidity: asymptomatic and ≤10% NSVT/premature ventricular contraction (PVC) burden
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without electrolyte abnormality
1st line – 

reassurance + self-monitoring

NSVT is by definition a self-terminating event, and therefore usually no specific treatment is indicated. Rather, treatment is directed at any existing heart condition.

If investigations show that the NSVT is likely to be idiopathic (right ventricular outflow tract or fascicular origin, negative family history, normal 12-lead ECG and echocardiogram), and the NSVT/PVC burden is less than 10%, the patient can be discharged and re-evaluated if they experience new symptoms or changes in their clinical condition.[2]

no cardiac comorbidity: symptomatic NSVT or >10% asymptomatic NSVT/premature ventricular contraction (PVC) burden

1st line – correction of electrolyte abnormality

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ONGOING
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no cardiac comorbidity: symptomatic NSVT or >10% asymptomatic NSVT/premature ventricular contraction (PVC) burden
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with electrolyte abnormality
1st line – 

correction of electrolyte abnormality

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

1st line – beta-blocker or calcium-channel blocker

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ONGOING
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no cardiac comorbidity: symptomatic NSVT or >10% asymptomatic NSVT/premature ventricular contraction (PVC) burden
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without electrolyte abnormality
1st line – 

beta-blocker or calcium-channel blocker

On the rare occasion that NSVT produces symptoms in the absence of cardiac disease, medication may be indicated.[2]

Symptom correlation with the NSVT is necessary and usually accomplished by ambulatory ECG monitoring.

The far more common clinical scenario requiring treatment is when NSVT is associated with a high burden of PVCs (>10%), and reduced left ventricular function is present. In this setting, a trial of antiarrhythmic drugs, or referral for catheter ablation, should be considered to determine whether left ventricular function improves with reduction in PVC burden.[1]

Beta-blockers (e.g., metoprolol, atenolol) or calcium-channel blockers (generally used when beta-blockers are contraindicated, e.g., asthma) are usually sufficient to control symptoms.

Primary options

metoprolol tartrate: 50-200 mg/day orally (immediate-release) given in 2 divided doses

OR

atenolol: 25-100 mg orally once daily

Secondary options

verapamil: 180-240 mg/day orally (immediate-release) given in 3-4 divided doses; 180-240 mg orally (extended-release) once daily

OR

diltiazem: 90-360 mg/day orally (immediate-release) given in 3-4 divided doses; 90-360 mg orally (extended-release) once daily

Consider – catheter ablation

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ONGOING
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no cardiac comorbidity: symptomatic NSVT or >10% asymptomatic NSVT/premature ventricular contraction (PVC) burden
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without electrolyte abnormality
Consider – 

catheter ablation

Treatment recommended for SOME patients in selected patient group

Catheter ablation may be considered early in the treatment course and has a high success rate, particularly with right ventricular outflow tract and fascicular origin NSVT, where it is recommended as first-line treatment.[2]​ It should also be considered in the setting of left ventricular dysfunction and persistent PVC burden >10% despite treatment of reversible conditions.

2nd line – antiarrhythmic

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ONGOING
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no cardiac comorbidity: symptomatic NSVT or >10% asymptomatic NSVT/premature ventricular contraction (PVC) burden
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without electrolyte abnormality
2nd line – 

antiarrhythmic

Antiarrhythmic agents such as flecainide or propafenone may be used in patients who fail therapy with beta-blockers and/or calcium-channel blockers who are not candidates for catheter ablation or in whom catheter ablation is ineffective.

Primary options

flecainide: 100-200 mg orally twice daily

OR

propafenone: 150-300 mg orally (immediate-release) three times daily

chronic coronary artery disease (CAD)

1st line – lifestyle modification

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ONGOING
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chronic coronary artery disease (CAD)
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without heart failure
1st line – 

lifestyle modification

Modifiable risk factors should be considered in all patients. These include weight management, dietary change, lipid lowering, increased physical activity, and smoking cessation.

Plus – optimization of medical therapy

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ONGOING
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chronic coronary artery disease (CAD)
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without heart failure
Plus – 

optimization of medical therapy

Treatment recommended for ALL patients in selected patient group

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

Patients with underlying chronic CAD should be started on aspirin, which should be continued indefinitely. For patients with a contraindication to aspirin therapy, clopidogrel is a reasonable alternative.[61][62]​​​​

Statins are at the core of lipid management and most patients should receive high-intensity treatment, with patients over 75 years recommended moderate-to-high-intensity statin treatment.[63]

In terms of antihypertensive therapy, US guidelines recommend that patients with stable ischemic heart disease should be treated to a target of less than 130/80 mmHg.[63] European guidelines recommend 120 to 130 mmHg for most patients with stable ischemic heart disease, with a higher target of 130 to 140 mmHg for patients older than 65 years old.[64]

See Stable ischemic heart disease.

1st line – lifestyle modification

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ONGOING
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chronic coronary artery disease (CAD)
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with heart failure
1st line – 

lifestyle modification

Patients with NSVT and CAD, combined with a decreased left ventricular ejection fraction (≤40%), are at high risk of death from cardiac causes.[1][42]​ Modifiable risk factors should be addressed, including weight management, dietary change, increased physical activity, smoking cessation, and avoiding excessive dietary sodium intake.[58]

Plus – antifailure therapy

Back
ONGOING
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chronic coronary artery disease (CAD)
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with heart failure
Plus – 

antifailure therapy

Treatment recommended for ALL patients in selected patient group

Medications such as beta-blockers, ACE inhibitors, aldosterone receptor antagonists, aspirin, and statins reduce overall mortality and incidence of sudden cardiac death in patients with heart failure.[48][55][56]​​[57]​​ Angiotensin-II receptor antagonists can be used as an alternative in patients intolerant of ACE inhibitors.

Diuretics have no effect on mortality and are usually indicated to help relieve symptoms of fluid overload.

A sodium-glucose cotransporter 2 (SGLT2) inhibitor (e.g., dapagliflozin, empagliflozin) is recommended, in addition to optimal medical therapy, for patients with heart failure with reduced ejection fraction, regardless of diabetes status.[58][65]​​ There is limited evidence for its use in patients with renal impairment.

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

See Chronic heart failure, Acute heart failure.

Consider – implantable cardioverter defibrillator (ICD) implantation

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ONGOING
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chronic coronary artery disease (CAD)
|
with heart failure
Consider – 

implantable cardioverter defibrillator (ICD) implantation

Treatment recommended for SOME patients in selected patient group

Electrophysiologic testing is indicated for risk stratification. In patients with sustained inducible VT, ICD implantation has been shown to reduce the risk of death and cardiac arrest independently of New York Heart Association class.[1]​​[2][42]

post-myocardial infarction (MI)

1st line – early reperfusion + optimization of medical therapy

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ONGOING
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post-myocardial infarction (MI)
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without heart failure
1st line – 

early reperfusion + optimization of medical therapy

Early reperfusion decreases overall prevalence of NSVT following acute MI.[9]

Optimization of medical therapy including beta-blockers, ACE inhibitors, antiplatelet therapy, and statins, reduces the risk of sudden cardiac death following acute MI.[43][44][45][46][47][48][49]

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

See Non-ST-elevation myocardial infarction, ST-elevation myocardial infarction.

Plus – lifestyle modification

Back
ONGOING
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post-myocardial infarction (MI)
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without heart failure
Plus – 

lifestyle modification

Treatment recommended for ALL patients in selected patient group

Modifiable risk factors such as obesity and smoking should be addressed with a carefully planned exercise, diet, and weight loss program to further reduce the incidence of sudden cardiac death.[51][52]

1st line – early reperfusion + antifailure therapy

Back
ONGOING
|
post-myocardial infarction (MI)
|
with heart failure
1st line – 

early reperfusion + antifailure therapy

Early reperfusion decreases overall prevalence of NSVT following acute MI.[9]

Medications such as beta-blockers, ACE inhibitors, aldosterone receptor antagonists, aspirin, and statins reduce overall mortality and incidence of sudden cardiac death in patients with heart failure.[48][55][56]​​[57]​​ Angiotensin-II receptor antagonists can be used as an alternative in patients intolerant of ACE inhibitors.

Diuretics have no effect on mortality and are usually indicated to help relieve symptoms of fluid overload.

Electrolyte abnormalities, most commonly hypokalemia, hyperkalemia, and hypomagnesemia, may trigger NSVT in patients with or without cardiac disease. These disturbances should be corrected as efficiently as possible.

See Non-ST-elevation myocardial infarction, ST-elevation myocardial infarction, Chronic heart failure, Acute heart failure. 

Plus – lifestyle modification

Back
ONGOING
|
post-myocardial infarction (MI)
|
with heart failure
Plus – 

lifestyle modification

Treatment recommended for ALL patients in selected patient group

Modifiable risk factors such as obesity and smoking should be addressed with a carefully planned exercise, diet, and weight loss program to further reduce the incidence of sudden cardiac death.[51][52]

Consider – implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy plus ICD (CRT-D)

Back
ONGOING
|
post-myocardial infarction (MI)
|
with heart failure
Consider – 

implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy plus ICD (CRT-D)

Treatment recommended for SOME patients in selected patient group

ICD is recommended for patients who are at least 40 days post-MI with class II/III heart failure, left ventricular ejection fraction (LVEF) ≤35%, and who have a reasonable expectation of meaningful survival for >1 year.[58] ICD is similarly indicated in patients with class I heart failure if LVEF is ≤30%.[58]

Comorbid conditions that may attenuate the survival benefit of ICDs include chronic kidney disease, diabetes, peripheral vascular disease, and elevated BUN (27 to 50 mg/dL).

It is important to note that the decision to implant an ICD is based on cardiac function and symptoms rather than the presence or absence of NSVT.[53]

In some patients with heart failure, particularly those at risk for sudden cardiac death and who also have discordant contraction of left ventricular function, a cardiac resynchronization therapy (CRT) device can be used, usually in combination with an ICD (CRT-D).[59] The CRT device is designed to improve cardiac function by providing more coordinated contraction of the left ventricle. However, frequent episodes of NSVT or frequent premature ventricular contractions can interfere with the normal function of the device.

idiopathic dilated or hypertrophic cardiomyopathy

1st line – implantable cardioverter defibrillator (ICD)

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ONGOING
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idiopathic dilated or hypertrophic cardiomyopathy
|
risk factors for sudden cardiac death
1st line – 

implantable cardioverter defibrillator (ICD)

ICD placement should be considered for patients with hypertrophic cardiomyopathy and one of the major risk factors for sudden cardiac death including sudden cardiac arrest, spontaneous sustained VT, unexplained syncope, family history of sudden cardiac death in a first-degree relative, ventricular septal wall thickness >30 mm, NSVT on 24-hour ambulatory ECG monitoring, and hypotension in response to exercise. Other risk factors include atrial fibrillation, myocardial ischemia, left ventricular outflow obstruction, a high-risk mutation, and patients who compete in high-intensity physical exercises.[1]

European Society of Cardiology guidelines recommend considering ICD placement in patients with: NSVT and dilated cardiomyopathy/hypokinetic nondilated cardiomyopathy, a pathogenic mutation in the LMNA gene, and a 5-year estimated risk of life-threatening ventricular arrhythmia of ≥10%.[2]

See Hypertrophic cardiomyopathy.

1st line – implantable cardioverter defibrillator (ICD)

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ONGOING
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idiopathic dilated or hypertrophic cardiomyopathy
|
left ventricular ejection fraction (LVEF) reduced
1st line – 

implantable cardioverter defibrillator (ICD)

ICD placement is recommended for all patients with underlying idiopathic cardiomyopathy plus ejection fraction ≤35% and class II/III heart failure. For patients with LVEF ≤35% and class I heart failure, ICD placement should be considered.[1]

European Society of Cardiology guidelines recommend considering ICD placement in patients with NSVT and symptomatic arrhythmogenic right ventricular cardiomyopathy with moderate right ventricle (<40%) and/or left ventricle (<45%) dysfunction.[2]

See Hypertrophic cardiomyopathy.

1st line – observation + monitoring

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ONGOING
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idiopathic dilated or hypertrophic cardiomyopathy
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left ventricular ejection fraction (LVEF) not reduced without risk factors for sudden cardiac death
1st line – 

observation + monitoring

Close observation, but no activity restriction is recommended for patients with hypertrophic cardiomyopathy with identified genetic mutations but no overt signs of disease or major risk factors for sudden cardiac death.[60]

Implantable cardioverter defibrillator is not indicated for patients with NSVT and idiopathic cardiomyopathy with good left ventricular function.

See Hypertrophic cardiomyopathy.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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