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.
This man is very likely to have sustained ventricular tachycardia (VT) given his history of ischaemic 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 ICD is indicated by NICE criteria as he has an EF <35%, sustained VT, ischaemic aetiology, and NYHA class III or less. 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.