[Diagnosis of ischemia and revascularization in patients with ventricular tachyarrhythmia]

Area of Science:

• Cardiology
• Electrophysiology

Background:

• Sustained ventricular tachyarrhythmia typically arises from structural heart disease, especially coronary artery disease (CAD).
• Monomorphic ventricular tachycardia (VT) in CAD is usually not triggered by acute ischemia, unlike polymorphic VT or ventricular fibrillation (VF).
• Elevated sensitive troponin T in sustained VT complicates distinguishing acute ischemia as the cause, as chronic coronary artery sclerosis can create an oxygen supply-demand mismatch.

Purpose of the Study:

• To clarify the role of acute ischemia in monomorphic VT within the context of CAD.
• To guide the appropriate use of acute coronary angiography and revascularization in patients with VT.
• To prevent misinterpretation of monomorphic VT as solely caused by coronary stenosis, which could lead to withholding necessary antiarrhythmic therapy.

Main Methods:

• Review of clinical presentations and diagnostic approaches for monomorphic and polymorphic VT/VF in CAD.
• Analysis of the impact of acute coronary angiography and revascularization on rhythm stabilization in different VT types.
• Evaluation of diagnostic criteria for ischemia in the context of tachycardia-induced troponin elevation.

Main Results:

• Acute coronary angiography and revascularization are often unnecessary for monomorphic VT and do not typically improve rhythm stabilization.
• Misinterpreting monomorphic VT as solely due to coronary stenosis can lead to withholding essential antiarrhythmic treatments.
• Acute coronary angiography and revascularization are beneficial for polymorphic VT/VF, signs of ischemia, or chest pain preceding VT/VF, and in VT with newly diagnosed reduced left ventricular function.

Conclusions:

• Monomorphic VT in CAD generally does not require acute coronary angiography or revascularization unless specific criteria are met.
• Distinguishing between ischemia-driven VT and other causes is crucial for appropriate therapeutic decisions, including antiarrhythmic drug use.
• Coronary angiography is indicated for polymorphic VT/VF, suspected acute ischemia, and in specific patient groups with VT before interventions like catheter ablation.