Long-term management-wide-complex tachycardias (WCTS)

(EHJ 2015;36:2793; Circ 2018;138:e272; NEJM 2019;380:1555)

• Workup: echo to ✓ LV fxn, cath or stress test to r/o ischemia, ? MRI and/or RV bx to look for infiltrative CMP or ARVC, ? EP study to assess for VT in Pts w/o ICD indication
• ICD: 2° prevention for VT/VF arrest (unless due to reversible cause) or cardiac syncope with inducible VT on EP study. 1° prev. if high risk, eg, EF <30–35% (>40 d after MI, >90 d after revasc), ? ARVC, ? Brugada, certain LQTS, severe HCMP. See “Cardiac Rhythm Mgmt Devices.” Wearable vest if reversible or waiting for ICD? (NEJM 2018;379:1205). Antitachycardia pacing (ATP = burst pacing faster than VT) can terminate VT w/o shock.
• Meds: βB, AAD (amio, sotalol, mexiletine); verapamil if LVOT VT
• If med a/w TdP → QT >500 ± PVCs: d/c med, replete K, give Mg, ± pacing (JACC 2010;55:934)
• Ablate: if isolated VT focus or if recurrent VT triggering ICD firing (↓ VT storm by 34%; NEJM 2016;375:111); stereotactic radioablation under investigation (Circ 2019;139:313).