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Amiodarone versus Lignocaine in resistant ventricular tachycardia

Three Part Question

In [patients with resistant ventricular tachycardia] is [intravenous amiodarone superior to lignocaine] in terms of [mortality benefit].

Clinical Scenario

You are part of cardiac arrest team involved in resuscitating a 60 year old female who has pulseless ventricular tachycardia (VT), inspite of receiving three shocks , she is still in VT. She was given amiodarone boluses but with no response. You wonder if lignocaine would have had a better outcome in this case.

Search Strategy

EMBASE (1974 July 2007) and MEDLINE (1950 July 2007) using the OVID interface
MEDLINE: [ exp Ventricular Tachycardia OR Tachycardia Ventricular dt.de. OR Tachycardia Ventricular-mo.de. OR Tachycardia Ventricular pc.de. OR Tachycardia Ventricular th.de] AND [ exp Amiodarone OR Amiodarone w.de] AND [ exp Lignocaine OR Lignocaine w.de] AND [exp mortality OR survival rate de.] Combine EMBASE and MEDLINE search results.

Search Outcome

37 papers were identified of which 1 was relevant describing a retrospective medical record review. On expanding the search criteria to Ventricular fibrillation, 2 clinical trials were identified which were significant.

Comment(s)

Most of the search result papers were review article based on the above 2 trials. The ALIVE trial was focused on patients with out of hospital cardiac arrest. ARREST trial focused on outcomes of using amiodarone (compared with placebo) in out of hospital cardiac arrest patients. The primary outcome for these two trials was mainly survival to hospital admission. Based on results of ARREST trial, amiodarone replaced lignocaine as a first line antiarrrhythmic for pulseless VF/VT in 2000 guidelines. The results of these RCTs differ significantly from the retrospective medical record review of in-hospital cardiac arrest. Given the fact that it is the most recent study done, trials have not yet been done to compare outcomes in in-hospital cardiac arrest.

Clinical Bottom Line

Following the current guidelines and based on the evidence available so far, amiodarone has proven to have better (short term) outcome but further trials are required to prove its efficacy in long term and in in-hospital cardiac arrest.