Is ventricular tachycardia (VT) an indication for pacemaker placement?

Ventricular Tachycardia and Pacemaker Implantation

Ventricular tachycardia alone is not an indication for pacemaker placement; instead, an implantable cardioverter-defibrillator (ICD) is the recommended device for patients with ventricular tachycardia. 1

Primary Management of Ventricular Tachycardia

• Ventricular tachycardia (VT) is typically managed with an implantable cardioverter-defibrillator (ICD) rather than a standard pacemaker, as ICDs can both detect and terminate life-threatening ventricular arrhythmias through defibrillation 1
• The prognosis of recurrent ventricular tachycardia resistant to antiarrhythmic drugs is poor, with patients frequently experiencing sudden cardiac death, making appropriate device therapy crucial 1
• Current guidelines from the American College of Cardiology/American Heart Association recommend ICDs for patients with documented episodes of hemodynamically significant ventricular tachycardia 1

Limited Role of Pacemakers in VT Management

• Permanent pacemakers are only indicated for VT in very specific circumstances:

  • Class I indication: For sustained pause-dependent VT, with or without QT prolongation 1
  • Class IIb indication: For sustained VT only when all other therapies (medications, ablation, ICDs) are ineffective or inapplicable AND the efficacy of pacing is thoroughly documented 1

• Anti-tachycardia pacing (ATP) features are now incorporated into modern ICDs rather than standalone pacemakers, allowing for both pacing termination of VT and backup defibrillation if pacing fails 1

Special Considerations

• In patients with long QT syndrome who develop pause-dependent VT, permanent pacing (often with beta blockade) may be reasonable (Class IIa recommendation) 1
• Pacemakers may be considered for VT only after extensive testing to ensure they can safely terminate the arrhythmia without accelerating it or inducing ventricular fibrillation 1
• Standalone anti-tachycardia pacemakers for VT have largely been replaced by ICDs with ATP capabilities, as pacing alone carries the risk of accelerating VT or converting it to ventricular fibrillation 1, 2

Potential Risks and Pitfalls

• Using ventricular pacing to terminate tachycardias carries risks of:

  • Acceleration of the tachycardia 1
  • Conversion to ventricular fibrillation 1, 3
  • Inappropriate therapy delivery if the device misidentifies the arrhythmia 2

• Pacemaker programming features designed to prevent pacemaker-mediated tachycardia can paradoxically induce cycle length variability that may trigger polymorphic VT in susceptible patients 3

Algorithm for Device Selection in VT

1. First-line therapy: ICD implantation for patients with hemodynamically significant VT 1
2. Consider pacemaker only if:
   • VT is clearly pause-dependent (especially with long QT syndrome) 1
   • All other therapies have failed or are contraindicated 1
   • Thorough electrophysiologic testing confirms that pacing can safely terminate the arrhythmia 1

In conclusion, while pacemakers may have a limited role in specific VT scenarios, they are not the primary indicated device for managing ventricular tachycardia in most clinical situations.