A perspective on ventricular arrhythmias: patient assessment for therapy and outcome

Clinical management of patients with ventricular arrhythmias continues to evolve. It is generally accepted that patients with sustained ventricular tachyarrhythmias (ventricular tachycardia [VT] or fibrillation) require treatment. It is also generally accepted that patients with frequent or complex ventricular ectopy or nonsustained VT, in the absence of underlying heart disease, do not require treatment unless relief of symptoms is warranted. Whether patients with frequent or complex ventricular ectopy or nonsustained VT require treatment in the presence of underlying organic heart disease remains uncertain. The concern is that these ventricular arrhythmias may be a precursor for sustained, potentially life-threatening ventricular tachyarrhythmias. Available data suggest that patients with underlying heart disease, particularly coronary artery disease and a previous myocardial infarction, who manifest frequent or complex ventricular ectopy or nonsustained VT are at increased risk for sudden cardiac death. However, no studies have shown that treatment of these arrhythmias will affect outcome. Data are accumulating to suggest that use of the principles of risk stratification permits identification of patients at very high risk for developing sustained ventricular tachyarrhythmias. Carefully designed clinical trials are required before one can provide firm guidelines for the management of these patients. Nevertheless, when several risk factors for sudden cardiac death (e.g., abnormal ejection fraction, a late potential on a signal-averaged electrocardiogram, and frequent or complex ventricular ectopy or nonsustained VT) are present in a patient, especially after a recent myocardial infarction, invasive electrophysiologic testing may help identify those who need treatment (sustained VT is inducible) and those who do not (no sustained VT is inducible).