Management of ventricular tachycardia storm in patients with structural heart disease

Table 2 Anti-arrhythmic medications for acute and long-term treatment of electrical storm

		Acute management	Long-term treatment	Desired plasma concentration
β-blockers	Propranolol	Bolus: 0.15 mg/kg IV over 10 min	10-40 mg by mouth three-four times a day	NA
	Metoprolol	Bolus: 2-5 mg IV every 5 min up to 3 doses in 15 min	25 mg by mouth twice a day up to 200 mg a day	NA
	Esmolol	Bolus: 300 to 500 mg/kg IV for 1 min	Not recommended	NA
		Infusion: 25-50 mg/kg per minute up to a maximum dose of 250 mg/kg per minute (titration every 5-10 min)
Class III agents	Amiodarone	Bolus: 150 mg IV over 10 min, up to total 2.2 g in 24 h	Oral load: 800 mg by mouth twice a day until 10 g total	1.0-2.5 μg/mL
				No efficacy proven for plasma concentrations < 0.5 μg/mL
		Infusion: 1 mg/min for 6 h, then 0.5 mg/min for 18 h	Maintenance dose: 200-400 mg by mouth daily	Serious toxicity risk for plasma concentrations > 2.5 μg/mL
	Sotalol	Not recommended	80 mg by mouth twice a day, up to 160 mg twice a day (serious side effects > 320 mg/d)	1-3 µg/mL (not of great value, usually monitored by QT prolongation with indication to reduction/discontinuation if prolongation > 15%-20%)
Class I agents	Procainamide	Bolus: 10 mg/kg IV over 20 min	3-6 g by mouth daily fractionated in ≥ 3 administrations	4-12 μg/mL
		Infusion: up to 2-3 g/24 h
	Lidocaine	Bolus: 1.0 to 1.5 mg/kg IV, repeat dose of 0.5-0.75 mg/kg IV up to a total dose of 3 mg/kg	Not recommended	2-6 μg/mL
		Infusion: 20 μcg/kg per minute IV
	Mexiletine	Not recommended	200 mg by mouth three times a day, up to 400 mg by mouth three times a day	0.6-1.7 μg/mL