Assess urgency before ordering a monitor
Ongoing wide-complex tachycardia, syncope with concerning features, hypotension, ischemic chest discomfort, acute heart failure, or altered mental status requires emergency evaluation. Activate EMS. Do not delay transfer to obtain a perfect tracing.
Manage an undifferentiated wide-complex tachycardia as possible VT. A patient who is awake or has a measurable BP can still have VT. Avoid empiric verapamil or diltiazem for an uncertain wide-complex rhythm.[5]
For the stable patient
- History: symptoms, exertional relationship, syncope, prior MI/HF, family sudden death, stimulant exposure, and medication changes.
- EKG: capture ectopy when possible; review QRS morphology, QTc, ischemic changes, and conduction disease.
- Monitoring: quantify PVC burden, morphologies, NSVT episodes, and symptom correlation. Review strips and recording duration.
- Targeted tests: potassium, magnesium, renal function, and other labs guided by context.
[3]Coordinate cardiac evaluation: echocardiography assesses function; ischemia testing and cardiac MRI are selected according to symptoms, risk, and suspected substrate. A normal echo alone does not establish that an atypical ventricular arrhythmia is benign.[4]
When to refer
Ongoing VT, instability, or repeated ICD shocks
Emergency assessment.
NSVT with syncope, reduced EF, known scar, or concerning family history
Expedited cardiology/EP evaluation; emergency disposition if current clinical risk warrants.
Frequent PVCs, impaired EF, significant symptoms, or PVCs limiting CRT pacing
Cardiology/EP referral for substrate assessment and suppression options.
Occasional PVCs with reassuring evaluation
Explain findings, address triggers, and plan follow-up.
This referral framework applies the risk and treatment principles in the cited guidance; timing remains individualized.[3][4]
Two clinic pitfalls
Apparent bradycardia: bigeminy can create a pulse deficit. Compare the electrical rate on EKG with the palpable pulse before attributing the finding to sinus-node disease.[9]
“Only a short run”: NSVT needs clinical context. Send the actual EKG/monitor strips, symptoms, burden, EF, medications, and relevant labs with the referral.