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EMedHome's Clinical Pearl

Procainamide More Effective and Safer for VT

doi: 10.1097/01.EEM.0000616476.30357.18
EMedHome's Clinical Pearl


Lidocaine is one of the least effective agents for converting ventricular tachycardia (VT) outside of the acute myocardial infarction setting. (Am J Emerg Med. 2019;37[7]:1340.)

Contrary to widespread belief, IV procainamide is more effective and safer than IV amiodarone for the acute conversion of VT. (Am J Emerg Med. 2019;37[7]:1340; Acad Emerg Med. 2019;26[9]:1099,; Eur Heart J. 2017;38[17]:1329,; Emerg Med J. 2015;32[2]:161.)

IV procainamide is the only agent that carries a class IIA indication for the pharmacologic conversion of VT, and it is listed ahead of IV amiodarone (class IIB) in the ACLS guidelines. (Am J Emerg Med. 2019;37[7]:1340; Acad Emerg Med. 2019;26[9]:1099,; Eur Heart J. 2017;38[17]:1329,; Emerg Med J. 2015;32[2]:161; Circulation. 2010;122[16 Suppl 2]:S345;

On the other hand, IV amiodarone is the most effective agent in preventing recurrences of VT, making its use in repetitive VT appropriate. Frequently, IV procainamide is used for terminating VT, followed by IV amiodarone for preventing recurrence. (Am J Emerg Med. 2019;37[7]:1340.) The safety of administering procainamide and amiodarone in sequence, however, has not been clearly established.

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