A new substudy of the VANISH2 trial suggests that for patients with prior myocardial infarction and ventricular tachycardia (VT) who are eligible for sotalol, catheter ablation leads to better outcomes than antiarrhythmic drug (AAD) therapy.¹ For patients eligible only for amiodarone, efficacy was comparable, but amiodarone was associated with a significant increase in adverse events.
Methodology
This prespecified substudy of the VANISH2 (NCT02830360) trial analysed data from 416 patients with prior myocardial infarction and clinically significant VT. The multicentre, randomised controlled trial stratified patients based on their eligibility for AADs.
Patients with a better clinical profile (e.g., estimated glomerular filtration rate ≥30 mL/min, NYHA class I-II, left ventricular ejection fraction ≥20%) were placed in the sotalol-eligible stratum (n=199) and randomised 1:1 to receive either catheter ablation or sotalol. All other patients were placed in the amiodarone-eligible stratum (n=217) and randomised 1:1 to catheter ablation or amiodarone.
The primary endpoint was a composite of death, appropriate implantable cardioverter-defibrillator (ICD) shock, VT storm, or treated sustained VT below the ICD detection limit, assessed more than 14 days after randomisation. The median follow-up was 4.3 years.
Results
In the sotalol-eligible stratum, catheter ablation was associated with a significantly lower risk of the primary composite endpoint compared to sotalol therapy (46% vs 59%; HR: 0.64; 95% CI: 0.43–0.94; p=0.02). This was primarily driven by lower rates of appropriate ICD shocks (28% vs 45%; HR: 0.54) and treated sustained VT below the ICD detection rate (2% vs 17%; HR: 0.12).
In the amiodarone-eligible stratum, the efficacy of catheter ablation and amiodarone was comparable for the primary endpoint (55% vs 61%; HR: 0.86; 95% CI: 0.61–1.22). However, patients treated with amiodarone had a threefold higher rate of noncardiac death compared to those who received ablation (16.5% vs 5.6%). The amiodarone group also experienced higher rates of respiratory failure (11.0% vs 4.6%), heart failure hospitalisation (31.2% vs 19.4%), and pneumonia (11.9% vs 3.7%).
In Practice
These findings provide stratified evidence for managing VT in patients with ischaemic heart disease. For patients with a more stable clinical profile, first-line catheter ablation appears superior to sotalol for arrhythmia suppression. For those with more severe disease, the choice between ablation and amiodarone requires careful consideration of safety profiles. The VANISH2 Study Team concluded, "In the sotalol-eligible patients, ablation led to lower risk of the primary composite endpoint. In the amiodarone-eligible group, efficacy outcomes were comparable between ablation and amiodarone. Adverse events were more marked among patients randomized to amiodarone."¹
This study was funded by research grants from multiple industry sources, including Johnson and Johnson and Abbott.
Disclaimer
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References
1. Nery PB, Wells GA, Tang ASL, et al. Catheter ablation vs sotalol or amiodarone for ventricular tachycardia: a substudy of the VANISH2 trial. J Am Coll Cardiol. 2026;87(2):157–168. https://doi.org/10.1016/j.jacc.2025.09.1595
2. Sapp JL, Tang ASL, Parkash R, et al. Catheter ablation or antiarrhythmic drugs for ventricular tachycardia. N Engl J Med. 2025;392(8):737–747. https://doi.org/10.1056/NEJMoa2409501