"Ventricular Tachycardia Ablation versus Escalation of Antiarrhythmic Drugs".The New England Journal of Medicine. 2016. 375(2):111-121.PubMed•Full text•PDF

Clinical Question

Among patients with ischemic cardiomyopathy and an implantable cardioverter–defibrillator (ICD) with ventricular tachycardia despite antiarrhythmic drug therapy, is catheter ablation more effective than escalated antiarrhythmic drug therapy in reducing the rate of death, ventricular tachycardia storm, or appropriate ICD shock?

Bottom Line

Catheter ablation was more effective than escalated antiarrhythmic drug therapy in reducing the composite outcome of death, ventricular tachycardia storm, or appropriate ICD shock among patients with ischemic cardiomyopathy who have ventricular tachycardia despite antiarrhythmic drug therapy.

Major Points

Guidelines

Current guidelines recommend catheter ablation when antiarrhythmic drug therapy does not prevent recurrent ventricular tachycardia, although this recommendation has been based on expert opinion and nonrandomized case series. This trial provides evidence for preferring catheter ablation over escalated antiarrhythmic drug therapy to reduce recurrent ventricular tachycardia in this population.

Design

Multicenter, randomized, controlled trial.

Population

259 patients with ischemic cardiomyopathy and an ICD with ventricular tachycardia despite antiarrhythmic drugs.

Interventions

Patients were randomized to either catheter ablation (n=132) or escalated antiarrhythmic drug therapy (n=127).

Outcomes

Composite outcome of death at any time, ventricular tachycardia storm, or appropriate ICD shock.
Primary outcome occurred in 59.1% of the ablation group vs. 68.5% of the escalated-therapy group (HR 0.72; 95% CI, 0.53 to 0.98; P=0.04). No significant differences in mortality.

Criticisms

The trial was not powered to assess the effects of treatments on mortality and was conducted at experienced centers, limiting generalizability.

Funding

Canadian Institutes of Health Research with additional financial support from St. Jude Medical and Biosense Webster.

Further Reading

Key articles and guidelines for those interested in further information.