A 48-year-old man presents with syncope. ECG shows PR interval 280 ms, QRS duration 140 ms with LBBB morphology, and QT 480 ms. His echo shows LV wall motion abnormality. He undergoes EP study showing HV interval of 90 ms (normal <55 ms) and inducible ventricular tachycardia. The most appropriate intervention is:
- A Permanent pacemaker implantation for AV block
- B ICD (implantable cardioverter-defibrillator) implantation plus EP-guided antiarrhythmic therapy ✓
- C Catheter ablation of the HPS (His-Purkinje system) for LBBB correction
- D Long-term amiodarone therapy to suppress VT
Explanation
This patient has structural heart disease (wall motion abnormality suggesting ischemic cardiomyopathy), LBBB with a markedly prolonged HV interval (90 ms, indicating severe infra-Hisian conduction disease), inducible sustained VT on EP study, and syncope. Inducible VT at EP study in a patient with structural heart disease and syncope is a Class I indication for ICD implantation, which provides the best protection against sudden cardiac death. The prolonged HV interval indicates high-risk conduction disease and may additionally warrant pacing, but the primary concern is sudden cardiac death prevention via ICD. Amiodarone alone is inferior for SCD prevention. His-bundle pacing is a correction strategy, not appropriate acutely.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.