Management Of A Patient With Tachycardia In CCU

A 61-year-old with a history of a myocardial infarction 2 years ago with a known ejection fraction of 25% presents to A&E with a 2 hour history of mild palpitations. He is otherwise fit and well. His ECG monitoring shows a regular broad complex tachycardia at a rate of 170 bpm which self terminated before a 12-lead ECG was performed. His U&Es are normal. The patient’s blood pressure was 130/90 mmHg during the tachycardia and he was not unduly distressed. He is transferred to CCU where a 12-lead ECG shows LBBB with a QRS duration of 100 ms.
What will be his appropriate management?
A. He needs an ICD (Implantable Cardioverter Defibrillator)
B. He needs an urgent revascularization
C. He needs an EP study (electrophysiology study)
D. He tolerated his tachycardia well; therefore it is likely to be an SVT with aberrancy
E. He should be commenced on flecainide

Answer:
A. He needs an ICD (Implantable Cardioverter Defibrillator)

Discussion: This man is very likely to have sustained ventricular tachycardia (VT) given his history
of ischemic heart disease, impaired ejection fraction, and broad complex tachycardia.
The fact that he has tolerated it well is not an indication that it is an SVT, although this is
possible. Therefore an Implantable Cardioverter Defibrillator (ICD) is indicated by NICE criteria as he has an EF <35%, sustained VT, ischemic etiology, and a heart failure of class III or less according to New York Heart Association (NYHA) Functional Classification . It should be noted that this is a
secondary prevention indication despite the fact the patient does not appear to have been
compromised by his VT.
NICE recommends a VT stimulation study for non-sustained VT (NSVT) and EF <35%, but the patient already meets criteria for an ICD and therefore this would be a redundant investigation. Flecainide is contraindicated in patients with established IHD or structural heart disease.