A 55-year-old man post-anterior STEMI develops sustained monomorphic ventricular tachycardia (VT) on day 3. His LVEF is 30%. He is haemodynamically stable. The VT terminates with IV amiodarone. What is the MOST appropriate long-term management?
- A ICD implantation after >40 days and on optimal medical therapy, contingent on LVEF <35% ✓
- B ICD implantation before hospital discharge
- C Oral amiodarone for 3 months, then re-evaluate LVEF before ICD decision
- D Catheter ablation as first-line therapy given haemodynamic stability
Explanation
Per ACC/AHA guidelines, ICD implantation for primary/secondary prevention post-MI requires waiting ≥40 days after MI to allow LV remodelling and myocardial recovery. LVEF should be reassessed on optimal medical therapy (beta blocker, ACEi, MRA) as EF may recover. Early ICD (<40 days post-MI) in the DINAMIT trial did not reduce mortality (fatal arrhythmias were replaced by non-arrhythmic deaths). If LVEF remains ≤35% after 40 days on OMT, ICD is indicated. Sustained VT in the acute/subacute period is a Class I indication for ICD after recovery. Catheter ablation is used for refractory or storm VT, not as primary long-term management.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.