VANISH2: Antiarrhythmic drug therapy or catheter ablation in prior myocardial infarction complicated by ventricular tachycardia?

For patients with prior myocardial infarction (MI) and ventricular tachycardia (VT), first-line catheter ablation may be preferred over antiarrhythmic drug therapy, reducing recurrent arrhythmia outcomes, according to the results of the VANISH2 trial.

“VT in the setting of a prior MI may result in severe symptoms, defibrillator shocks, an impaired quality-of-life, and a declined survival,” outlined Dr John Sapp (Queen Elizabeth II Health Sciences Centre, Canada) [1,2]. The multicentre, phase 4 VANISH2 study (NCT02830360) compared groups of patients to assess whether antiarrhythmic drug therapy or catheter ablation should be the first line of therapy for this population. The study randomised 416 participants with a prior MI and VT who had an implanted defibrillator 1:1 to antiarrhythmic drug therapy or catheter ablation. Depending on disease characteristics, participants in the drug group received amiodarone or sotalol. The primary endpoint was the first occurrence of death, appropriate shock, VT storm, or treated sustained VT below detection.

After a median 4.3 years of follow-up, catheter ablation was superior to antiarrhythmic drug therapy (HR 0.75; 95% CI 0.58–0.97; P=0.028; see Figure). “The effect was mainly driven by a reduction in treated sustained VT below the detection limit of the device after 14 days,” commented Dr Sapp. The effect appeared to be somewhat larger when sotalol was compared with ablation (HR 0.64; 95% CI 0.46–0.93) than when amiodarone was compared with ablation (HR 0.86; 95% CI 0.58–1.27).

Figure: Primary endpoint of the VANISH2 study [1]



Death was reported in 22.2% and 25.4% of the participants in the ablation and antiarrhythmic drug groups, respectively. Serious non-fatal adverse events occurred in 28.1% of the participants in the ablation arm and 30.5% of those in the antiarrhythmic drug arm. “In total, 21.6% of the participants in the antiarrhythmic drug arm had a drug-attributed adverse event leading to reduction or discontinuation compared with only 3.4% of the participants in the ablation arm,” added Dr Sapp.

“For patients with a prior MI and VT events, a strategy of first-line catheter ablation rather than antiarrhythmic drug therapy may lead to better health outcomes,” concluded Dr Sapp.

1. 
   
   1. Sapp JL, et al. Catheter ablation or antiarrhythmic drug therapy for ventricular tachycardia in ischemic cardiomyopathy: the VANISH 2 trial. LBS.02, AHA Scientific Sessions 2024, 16–18 November, Chicago, USA.
   2. Sapp JL, et al. N Engl J Med 2024; Nov 16. DOI: 10.1056/NEJMoa2409501.

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Posted on 3 February 2025