A 64 year old male with a past medical history of diabetes mellitus, coronary artery disease, and congestive heart failure is being evaluated for chest pain. His initial vital signs are within normal limits. His EKG is unchanged from previous showing a narrow-complex sinus rhythm. While he is in the emergency department, he reports feeling palpitations. The cardiac monitor records a monomorphic, wide-complex tachycardia at a rate of 140 beats/minute while his blood pressure is 132/80. What is the first-line medication for treatment of this patient’s condition?
A: adenosine
B: amiodarone
C: epinephrine
D: magnesium sulfate
E: procainamide
Answer: procainamide
This patient with a history of extensive cardiac disease is likely experiencing stable ventricular tachycardia (VT). The PROCAMIO study in 2017 demonstrated that procainamide is likely superior to amiodarone for termination of wide-complex tachycardia and associated with fewer major adverse cardiac events. Adenosine is commonly used in the management of supraventricular tachycardias but is unlikely to terminate a tachycardia of ventricular origin. Epinephrine is used for pulseless VT as part of the ACLS algorithm. Magnesium sulfate is used for polymorphic VT also known as Torsades De Pointes but is not first-line for monomorphic VT.
References:
Ortiz, M., Martín, A., Arribas, F., Coll-Vinent, B., Del Arco, C., Peinado, R., Almendral, J., & PROCAMIO Study Investigators (2017). Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal, 38(17), 1329–1335. https://doi.org/10.1093/eurheartj/ehw230
