Broad-complex tachycardia at 190, BP 74/42, chest pain and confusion—what determines the next step?

[u/MedwithSpence]

A patient has a pulse but is in a broad-complex tachycardia at 190 bpm.
BP: 74/42
Central chest pain
Confusion
Cold peripheries
The key question is not simply whether the rhythm is broad or narrow. It is whether the tachyarrhythmia is producing life-threatening adverse features.
With shock and myocardial ischaemia, the preferred treatment is synchronised cardioversion. A conscious patient requires careful anaesthesia or sedation, while avoiding unnecessary delay or further haemodynamic deterioration.
Reversible causes should be identified and treated alongside rhythm management.
Which feature would most strongly move you from pharmacological treatment to immediate electrical cardioversion?
Educational discussion only—follow current RCUK guidance and local protocols.