condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.) Basics topics (see "Patient education: Ventricular tachycardia (The Basics)") SUMMARY AND RECOMMENDATIONS Background Ventricular arrhythmias, including premature ventricular complexes (PVCs), ventricular tachycardia (VT), and ventricular fibrillation (VF), are common in patients with heart failure (HF) and cardiomyopathy, occurring in up to 95 percent of this population. (See 'Types of arrhythmia' above.) Pathogenesis Multiple factors may be responsible for ventricular arrhythmias in patients with HF and cardiomyopathy, including underlying structural heart disease, mechanical factors, neurohormonal factors, electrolyte disturbances, myocardial ischemia, and medications. (See 'Pathogenesis' above.) https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 12/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Clinical manifestations The type and intensity of symptoms, if present, will vary depending upon the type and duration of the ventricular arrhythmia along with the patient s overall clinical status and significant comorbid conditions. Patients may experience few or no symptoms with PVCs or short runs of nonsustained VT, or may present with syncope or sudden cardiac arrest due to sustained VT or VF. (See 'Clinical manifestations' above.) Diagnostic evaluation An ECG should be part of the standard evaluation for any patient with suspected PVCs, VT, or VF. The diagnostic evaluation beyond an ECG will vary depending upon the particular arrhythmia in question and the patient s prior investigations, but additional testing may include one or more of ambulatory ECG monitoring, exercise testing, echocardiography, and invasive electrophysiology studies. (See 'Diagnostic evaluation' above.) Management The management of ventricular arrhythmias in patients with HF and cardiomyopathy is multifaceted and includes HF therapy, arrhythmia control, and consideration of an implantable cardioverter-defibrillator (ICD) for primary or secondary prevention of sudden cardiac death (SCD). Heart failure Standard therapy for HF due to systolic dysfunction consists of a beta blocker; an angiotensin receptor neprilysin inhibitor, angiotensin converting enzyme inhibitor, or an angiotensin II receptor blocker (ARB); and in selected patients, an aldosterone antagonist. Digoxin and other inotropic agents are occasionally used for symptom control, while diuretics are given for congestive symptoms. (See 'Heart failure therapy' above.) Arrhythmia control The initial management of a patient with sustained VT depends on the hemodynamic stability of the patient ( algorithm 1), with emergency management required in unstable patients. Subsequent management of VT will be guided by the initial presentation (ie, hemodynamically stable or unstable) and the initial approach to treatment. Patients with symptomatic NSVT or PVCs should usually be treated with beta blockers as the initial therapy. (See 'Arrhythmia control' above.) Prevention of SCD Patients who have been resuscitated from sudden cardiac arrest (due to either sustained VT or VF) are candidates for, and generally should receive, an ICD for secondary prevention of SCD. Additionally, many patients with HF and cardiomyopathy (and left ventricular ejection fraction 35 percent) are candidates for ICD implantation as primary prevention of SCD. (See "Secondary prevention of sudden https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 13/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate cardiac death in heart failure and cardiomyopathy" and "Primary prevention of sudden cardiac death in patients with cardiomyopathy and heart failure with reduced LVEF".) ACKNOWLEDGMENT The UpToDate editorial staff acknowledges Leonard Ganz, MD, FHRS, FACC, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Hynes BJ, Luck JC, Wolbrette DL, et al. Arrhythmias in Patients with Heart Failure. Curr Treat Options Cardiovasc Med 2002; 4:467. 2. Francis GS. 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Sustained ventricular tachycardia in patients with idiopathic dilated cardiomyopathy: electrophysiologic testing and lack of response to antiarrhythmic drug therapy. Circulation 1984; 70:451. 12. Milner PG, Dimarco JP, Lerman BB. Electrophysiological evaluation of sustained ventricular tachyarrhythmias in idiopathic dilated cardiomyopathy. Pacing Clin Electrophysiol 1988; 11:562. 13. White CW, Mirro MJ, Lund DD, et al. Alterations in ventricular excitability in conscious dogs during development of chronic heart failure. Am J Physiol 1986; 250:H1022. 14. Dean JW, Lab MJ. Arrhythmia in heart failure: role of mechanically induced changes in electrophysiology. Lancet 1989; 1:1309. 15. Koilpillai C, Qui ones MA, Greenberg B, et al. Relation of ventricular size and function to heart failure status and ventricular dysrhythmia in patients with severe left ventricular dysfunction. Am J Cardiol 1996; 77:606. 16. Gottlieb SS, Baruch L, Kukin ML, et al. Prognostic importance of the serum magnesium concentration in patients with congestive heart failure. J Am Coll Cardiol 1990; 16:827. 17. Cooper HA, Dries DL, Davis CE, et al. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation 1999; 100:1311. 18. Stambler BS, Wood MA, Ellenbogen KA. Sudden death in patients with congestive heart failure: future directions. Pacing Clin Electrophysiol 1992; 15:451. 19. Holmes JR, Kubo SH, Cody RJ, Kligfield P. Milrinone in congestive heart failure: observations on ambulatory ventricular arrhythmias. Am Heart J 1985; 110:800. 20. Anderson JL, Askins JC, Gilbert EM, et al. Occurrence of ventricular arrhythmias in patients receiving acute and chronic infusions of milrinone. Am Heart J 1986; 111:466. 21. DiBianco R, Shabetai R, Kostuk W, et al. A comparison of oral milrinone, digoxin, and their combination in the treatment of patients with chronic heart failure. N Engl J Med 1989; 320:677. 22. Packer M, Carver JR, Rodeheffer RJ, et al. Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group. N Engl J Med 1991; 325:1468. 23. Dies F, Krell MJ, Whitlow P, et al. Intermittent dobutamine in ambulatory outpatients with chronic cardiac failure. Circulation 1986; 74(Suppl II):II. 24. Bouvy ML, Heerdink ER, De Bruin ML, et al. Use of sympathomimetic drugs leads to increased risk of hospitalization for arrhythmias in patients with congestive heart failure. https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 15/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Arch Intern Med 2000; 160:2477. 25. Gradman A, Deedwania P, Cody R, et al. Predictors of total mortality and sudden death in mild to moderate heart failure. Captopril-Digoxin Study Group. J Am Coll Cardiol 1989; 14:564. 26. Moss AJ, Davis HT, Conard DL, et al. Digitalis-associated cardiac mortality after myocardial infarction. Circulation 1981; 64:1150. 27. Bigger JT Jr, Fleiss JL, Rolnitzky LM, et al. Effect of digitalis treatment on survival after acute myocardial infarction. Am J Cardiol 1985; 55:623. 28. Ryan TJ, Bailey KR, McCabe CH, et al. The effects of digitalis on survival in high-risk patients with coronary artery disease. The Coronary Artery Surgery Study (CASS). Circulation 1983; 67:735. 29. Muller JE, Turi ZG, Stone PH, et al. Digoxin therapy and mortality after myocardial infarction. Experience in the MILIS Study. N Engl J Med 1986; 314:265. 30. Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336:525. 31. Middlekauff HR, Stevenson WG, Stevenson LW, Saxon LA. Syncope in advanced heart failure: high risk of sudden death regardless of origin of syncope. J Am Coll Cardiol 1993; 21:110. 32. Fonarow GC, Feliciano Z, Boyle NG, et al. Improved survival in patients with nonischemic advanced heart failure and syncope treated with an implantable cardioverter-defibrillator. Am J Cardiol 2000; 85:981. 33. Grimm W, Hoffmann J J , M ller HH, Maisch B. Implantable defibrillator event rates in patients with idiopathic dilated cardiomyopathy, nonsustained ventricular tachycardia on Holter and a left ventricular ejection fraction below 30%. J Am Coll Cardiol 2002; 39:780. 34. Knight BP, Goyal R, Pelosi F, et al. Outcome of patients with nonischemic dilated cardiomyopathy and unexplained syncope treated with an implantable defibrillator. J Am Coll Cardiol 1999; 33:1964. 35. Bitter T, Westerheide N, Prinz C, et al. Cheyne-Stokes respiration and obstructive sleep apnoea are independent risk factors for malignant ventricular arrhythmias requiring appropriate cardioverter-defibrillator therapies in patients with congestive heart failure. Eur Heart J 2011; 32:61. 36. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353:2001. 37. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 16/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate 1996; 334:1349. 38. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. Lancet 1999; 353:9. 39. Domanski MJ, Exner DV, Borkowf CB, et al. Effect of angiotensin converting enzyme inhibition on sudden cardiac death in patients following acute myocardial infarction. A meta-analysis of randomized clinical trials. J Am Coll Cardiol 1999; 33:598. 40. Cleland JG, Erhardt L, Murray G, et al. Effect of ramipril on morbidity and mode of death among survivors of acute myocardial infarction with clinical evidence of heart failure. A report from the AIRE Study Investigators. Eur Heart J 1997; 18:41. 41. Pitt B, Poole-Wilson PA, Segal R, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial the Losartan Heart Failure Survival Study ELITE II. Lancet 2000; 355:1582. 42. Pfeffer MA, Swedberg K, Granger CB, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet 2003; 362:759. 43. Solomon SD, Wang D, Finn P, et al. Effect of candesartan on cause-specific mortality in heart failure patients: the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) program. Circulation 2004; 110:2180. 44. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999; 341:709. 45. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348:1309. 46. Ramires FJ, Mansur A, Coelho O, et al. Effect of spironolactone on ventricular arrhythmias in congestive heart failure secondary to idiopathic dilated or to ischemic cardiomyopathy. Am J Cardiol 2000; 85:1207. 47. Santangeli P, Rame JE, Birati EY, Marchlinski FE. Management of Ventricular Arrhythmias in Patients With Advanced Heart Failure. J Am Coll Cardiol 2017; 69:1842. Topic 968 Version 29.0 https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 17/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate GRAPHICS Some reported causes and potentiators of the long QT syndrome Congenital Jervell and Lange-Nielsen syndrome (including "channelopathies") Romano-Ward syndrome Idiopathic Acquired Metabolic disorders Other factors Androgen deprivation therapy Hypokalemia Myocardial ischemia or infarction, especially with prominent T-wave inversions GnRH agonist/antagonist therapy Hypomagnesemia Bilateral surgical orchiectomy Hypocalcemia Diuretic therapy via electrolyte disorders particularly hypokalemia and hypomagnesemia Starvation Anorexia nervosa Herbs Liquid protein diets Cinchona (contains quinine), iboga (ibogaine), licorice extract in overuse via Intracranial disease Hypothyroidism electrolyte disturbances Bradyarrhythmias HIV infection Sinus node dysfunction Hypothermia Toxic exposure: Organophosphate insecticides AV block: Second or third degree Medications* High risk Adagrasib Cisaparide (restricted availability) Lenvatinib Selpercatinib Ajmaline Levoketoconazole Sertindole Amiodarone Methadone Sotalol Delamanid Arsenic trioxide Mobocertinib Terfenadine Disopyramide Astemizole Papavirine (intracoronary) Vandetanib Dofetilide Bedaquline Vernakalant Dronedarone Procainamide Bepridil Ziprasidone Haloperidol (IV) Quinidine Chlorpromazine Ibutilide Quinine Ivosidenib Moderate risk Amisulpride (oral) Droperidol Inotuzumab ozogamacin Propafenone Azithromycin Encorafenib Propofol https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 18/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Capecitabine Entrectinib Isoflurane Quetiapine Carbetocin Erythromycin Levofloxacin (systemic) Ribociclib Certinib Escitalopram Risperidone Lofexidine Chloroquine Etelcalcetide Saquinavir Meglumine antimoniate Citalopram Fexinidazole Sevoflurane Clarithromycin Flecainide Sparfloxacin Midostaurin Clofazimine Floxuridine Sunitinib Moxifloxacin Clomipramine Fluconazole Tegafur Nilotinib Clozapine Fluorouracil (systemic) Terbutaline Olanzapine Crizotinib Thioridazine Ondansetrol (IV > oral) Flupentixol Dabrafenib Toremifene Gabobenate dimeglumine Dasatinib Vemurafenib Osimertinib Deslurane Voriconazole Oxytocin Gemifloxacin Domperidone Pazopanib Gilteritinib Doxepin Pentamidine Halofantrine Doxifluridine Pilsicainide Haloperidol (oral) Pimozide Imipramine Piperaquine Probucol Low risk Albuterol Fingolimod Mequitazine Ranolazine (due to bradycardia) Alfuzosin Fluoxetine Methotrimeprazine Relugolix Amisulpride (IV) Fluphenazine Metoclopramide (rare reports) Rilpivirine Amitriptyline Formoterol Metronidazole (systemic) Romidepsin Anagrelide Foscarnet Roxithromycin Apomorphine Fostemsavir Mifepristone Salmeterol Arformoterol Gadofosveset Mirtazapine Sertraline Artemether- lumefantrine Glasdegib Mizolastine Siponimod Goserelin Nelfinavir Asenapine Solifenacin Granisetron Norfloxacin Atomoxetine Sorafenib Hydroxychloroquine (rare reports) Nortriptyline Benperidol Sulpiride Ofloxacin (systemic) Bilastine Hydroxyzine Tacrolimus (systemic) Olodaterol Bosutinib Iloperidone Osilodrostat Tamoxifen Bromperidol Indacaterol Oxaliplatin Telavancin Buprenorphine Itraconazole Ozanimod Telithromycin Buserelin Ketoconazole (systemic) Pacritinib Teneligliptin Ciprofloxacin (Systemic) Lacidipine Paliperidone Tetrabenazine Cocaine (Topical) Lapatinib Panobinostat Trazodone https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 19/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Degarelix Lefamulin Pasireotide Triclabendazole Desipramine Leuprolide Pefloxacin Triptorelin Deutetrabenazine Leuprolide- norethindrone Periciazine Tropisetron Dexmedetomidine** Pimavanserin Vardenafil Levalbuterol Dolasetron Pipamperone Vilanterol Levomethadone Donepezil Pitolisant Vinflunine Lithium Efavirenz Ponesimod Voclosporin Loperamide in Eliglustat Primaquine Vorinostat overdose Eribulin Promazine Zuclopenthixol Lopinavir Ezogabine Radotinib Macimorelin Mefloquine This is not a complete list of all corrected QT interval (QTc)-prolonging drugs and does not include drugs with either a minor degree or isolated association(s) with QTc prolongation that appear to be safe in most patients but may need to be avoided in patients with congenital long QT syndrome depending upon clinical circumstances. A more complete list of such drugs is available at the CredibleMeds website. For clinical use and precautions related to medications and drug interactions, refer to the UpToDate topic review of acquired long QT syndrome discussion of medications and the Lexicomp drug interactions tool. AV: atrioventricular; IV: intravenous; QTc: rate-corrected QT interval on the electrocardiogram. Classifications provided by Lexicomp according to US Food & Drug Administration guidance: Clinical Evaluation of QT/QTc Interval Prolongation and Proarrhythic Potential for Non-Antiarrhythmic Drugs Questions and Answers; Guidance for Industry US Food and Drug Administration, June 2017 (revision 2) available at: https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM 073161.pdf with additional data from CredibleMeds QT drugs list criteria may lead to some agents being classified differently by other sources. [1,2] . The use of other classification Not available in the United States. In contrast with other class III antiarrhythmic drugs, amiodarone is rarely associated with torsades de pointes; refer to accompanying text within UpToDate topic reviews of acquired long QT syndrome. Withdrawn from market in most countries due to adverse cardiovascular effects. IV amisulpride antiemetic use is associated with less QTc prolongation than the higher doses administered orally as an antipsychotic. Other cyclic antidepressants may also prolong the QT interval; refer to UpToDate clinical topic on cyclic antidepressant pharmacology, side effects, and separate UpToDate topic on tricyclic antidepressant poisoning. The "low risk" category includes drugs with limited evidence of clinically significant QTc prolongation or TdP risk; many of these drugs have label warnings regarding possible QTc effects or recommendations to avoid use or increase ECG monitoring when combined with other QTc prolonging drugs. https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 20/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Rarely associated with significant QTc prolongation at usual doses for treatment of opioid use disorder, making buprenorphine a suitable alternative for patients with methadone-associated QTc prolongation. Refer to UpToDate clinical topic reviews. * The United States FDA labeling for the sublingual preparation of dexmedetomidine warns against use in patients at elevated risk for QTc prolongation. Both intravenous (ie, sedative) and sublingual formulations of dexmedetomidine have a low risk of QTc prolongation and have not been implicated in TdP. Over-the-counter; available without a prescription. Not associated with significant QTc prolongation in healthy persons. Refer to UpToDate clinical topic for potential adverse cardiovascular (CV) effects in patients with CV disease. Data from: 1. Lexicomp Online. Copyright 1978-2023 Lexicomp, Inc. All Rights Reserved. 2. CredibleMeds QT drugs list website sponsored by Science Foundation of the University of Arizona. Available at http://crediblemeds.org/. Graphic 57431 Version 142.0 https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 21/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Algorithm for initial treatment of SMVT in responsive patients with a pulse SMVT: sustained monomorphic ventricular tachycardia; CV: cardioversion. Hemodynamically unstable patients have evidence of hemodynamic compromise, such as hypotension, altered mental status, chest pain, or heart failure. Hemodynamically stable patients should have none of these findings. Initial choice of pharmacologic agents includes: Intravenous lidocaine (1 to 1.5 mg/kg [typically 75 to 100 mg] at a rate of 25 to 50 mg/minute; lower doses of 0.5 to 0.75 mg/kg can be repeated every 5 to 10 minutes as needed), which may be more effective in the setting of acute myocardial ischemia or infarction Intravenous procainamide (20 to 50 mg/minute until arrhythmia terminates or a maximum dose of 17 mg/kg is administered) Intravenous amiodarone (150 mg IV over 10 minutes, followed by 1 mg/minute for the next six hours; bolus can be repeated if VT recurs) Electrical cardioversion should be synchronized if possible, using 100-joule biphasic shock or 200- joule monophasic shock. If first shock is unsuccessful, energy level should be escalated on subsequent shocks. Conditions associated with SMVT include myocardial ischemia, electrolyte disturbances (eg, hypokalemia, hypomagnesemia), drug-related proarrhythmia, and heart failure. https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 22/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Graphic 108831 Version 1.0 https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 23/24 7/6/23, 3:10 PM Ventricular arrhythmias: Overview in patients with heart failure and cardiomyopathy - UpToDate Contributor Disclosures Philip J Podrid, MD, FACC No relevant financial relationship(s) with ineligible companies to disclose. Wilson S Colucci, MD Grant/Research/Clinical Trial Support: Merck [Heart failure]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/ventricular-arrhythmias-overview-in-patients-with-heart-failure-and-cardiomyopathy/print 24/24