Po-04-238 coronary angiography and revascularization yield in acute sustained monomorphic ventricular tachycardia

Coronary angiography (CAG) is heuristically used for patients presenting with sustained monomorphic VT (SMVT) to assess for coronary artery disease (CAD) and exclude acute vessel occlusion. Current guidelines recommend considering revascularization to improve clinical outcomes. To determine the yield of CAG in patients presenting with SMVT and impact of revascularization on clinical outcomes. Diagnostic coding was used to identify all emergency patient admissions with a primary or secondary diagnosis of VT at a large tertiary referral center from 2017-2022. Repeat presentations, non-sustained/polymorphic VT and alternative arrhythmias were excluded after careful clinical record review. Out of 568 screened admissions, 257 individual patients were identified with first acute presentations with SMVT. 93 (36%) underwent inpatient CAG, of which 54 (58%) had normal/minor CAD and 39 (42%) had significant CAD. Of these, 30 (32%) were deemed to have chronic CAD for conservative therapy whilst 9 (10%) had inpatient revascularization. No acute vessel occlusions were identified. 31 (33%) of patients presented with VT storm. There was no significant difference in mean VT cycle length (P=0.764) or LVEF (P=0.595) between patients that did and did not undergo revascularization. 50% of patients with normal/minor CAD had ischemic ECG changes and 69% had abnormal serum troponin levels. On univariate analysis, the presence or degree of ST elevation (P=0.759) or depression (P=0.312) on 12-lead ECG was not associated with revascularization. The degree of serum troponin rise did not correlate with revascularization (tb=0.093, P=0.297). 4 out of the 9 revascularized patients underwent EPS, of which all 4 had inducible VT post-revascularization. 41% of patients undergoing CAG were ultimately classified with an ischemic cardiomyopathy phenotype, 37% non-ischemic cardiomyopathy (6% with bystander CAD) and 22% idiopathic. On a median follow-up of 19.5 months (IQR 7-38 months), VT recurrence (P=0.318), cardiac rehospitalization (P=0.396) and mortality (P=0.804) were not significantly different between those that did and did not undergo revascularization. In patients presenting with acute SMVT, the yield of CAG in identifying acutely significant CAD was low and classic clinical ischemia markers did not increase this yield. The minority that underwent revascularization did not have significantly different clinical outcomes.