An elderly patient with ischemic cardiomyopathy and an ejection fraction of 20% with inducible sustained VT: what therapy is most appropriate?

• A. Implantable Defibrillator
• B. Metoprolol (Lopressor)
• C. Radiofrequency Ablation
• D. Warfarin (Coumadin)

Answer: (A)

Implantable cardioverter-defibrillator therapy is the best choice because severe ischemic cardiomyopathy with a very reduced ejection fraction (20%) places the patient at high risk for sudden cardiac death from malignant ventricular arrhythmias. An ICD provides immediate termination of life‑threatening VT or VF, and trials show a survival benefit in this population, including older adults, as long as there’s reasonable life expectancy. The finding of inducible sustained VT adds to the risk profile, reinforcing the need for a device that can promptly interrupt dangerous rhythms.

Beta-blockers like metoprolol can help reduce arrhythmia burden but do not reliably prevent sudden death on their own in this setting. Radiofrequency ablation targets specific VT circuits and may reduce episodes, but it does not address the broader risk of sudden death as effectively as an ICD. Warfarin is not indicated here unless there is another indication such as atrial fibrillation or LV thrombus.