CLINICAL QUESTION: Among patients with ischemic cardiomyopathy and ventricular tachycardia, is catheter ablation or antiarrhythmic drug therapy a more effective initial strategy
BACKGROUND: Implantable cardioverter-defibrillators (ICDs) have been shown to improve survival in patients with prior myocardial infarction and ventricular tachycardia. However, ICDs do not prevent subsequent episodes of ventricular tachycardia. An earlier study, the VANISH trial, showed a role for ablation in patients when antiarrhythmic drug therapy was ineffective. Prior trials have not examined catheter ablation as first-line therapy.
STUDY DESIGN: Open-label, randomized trial
SETTING: 22 centers in Canada, the U.S., and France
SYNOPSIS: 416 patients with prior myocardial infarction and ventricular tachycardia were randomized to undergo catheter ablation or receive antiarrhythmic drug therapy. All patients had an ICD. Catheter ablation was performed within 14 days after randomization, and patients receiving antiarrhythmic drug therapy were given sotalol or amiodarone. Patients were followed for a median of 4.3 years. The primary composite end point of death from any cause or, more than 14 days after randomization, ventricular tachycardia storm, appropriate ICD shock, or sustained ventricular tachycardia treated by medical intervention occurred in 50.7% of the catheter ablation group and 60.6% of patients assigned to drug therapy (hazard ratio, 0.75; 95% CI, 0.58 to 0.97; P = 0.03). The difference between trial groups was due to a lower number of ICD shocks and episodes of treated ventricular tachycardia in the ablation group.
BOTTOM LINE: Consider catheter ablation as an initial management strategy in patients with ischemic cardiomyopathy and ventricular tachycardia.
CITATION: Sapp JL, et al. VANISH2 Study Team. Catheter ablation or antiarrhythmic drugs for ventricular tachycardia. N Engl J Med. 2025;392(8):737-747. doi: 10.1056/NEJMoa2409501.
Dr. Huang
Dr. Huang is a clinical professor of medicine in the division of hospital medicine and a physician advisor at UC San Diego Health in San Diego.