Efficacy and safety of catheter ablation versus antiarrhythmic drugs in patients with ischemic cardiomyopathy and ICD for secondary arrhythmia prevention: a systematic review and network meta-analysis
K Pamporis, D Tsiachris, C K Antoniou, A Kordalis, S Boveda, K Vlachos, P Jais, P Karakasis, P Theofilis, M Botis, N Milaras, P Kouvatsos, P A Goutis, A E Karanikola, K TsioufisAbstract
Background
Ventricular tachycardia ablation (VTA) and class III antiarrhythmic drugs (AADs) are commonly used strategies to prevent recurrent ventricular arrhythmias (VAs) in individuals with ischemic cardiomyopathy (ICM) who carry an implantable cardioverter-defibrillator (ICD). Although several randomized controlled trials (RCTs) have compared these approaches, their relative benefits remain uncertain.
Objective
To compare the efficacy and safety of VTA versus AAD (amiodarone or sotalol) for secondary prevention of VA in patients with ICM and an ICD using network meta-analysis (NMA) methods.
Methods
We systematically searched MEDLINE (PubMed), Scopus, the Cochrane Library, and ClinicalTrials.gov from inception to October 15, 2025, for RCTs evaluating VTA versus AAD therapy. Study screening, data extraction, and risk-of-bias assessment were performed independently by two reviewers. The principal effectiveness endpoints were appropriate ICD shocks and electrical storm (ES), while any serious adverse event was the primary safety endpoint. Random-effects frequentist NMA models generated risk ratios (RRs) with 95% confidence intervals (CIs).
Results
Thirteen studies (2,177 patients) were eligible. VTA significantly lowered the occurrence of appropriate ICD shocks versus AAD therapy (RR=0.68; 95% CI [0.47–0.99]; p=0.043). ES (RR=0.81; 95% CI [0.63–1.03]; p=0.088) and VA recurrence (RR=0.86; 95% CI [0.68–1.08]; p=0.197) were numerically reduced with VTA, although not statistically significant. VTA ranked highest overall and demonstrated superiority regarding heart failure (HF) decompensation (RR=0.76; 95% CI [0.58–0.99]; p=0.043) and undetected ventricular tachycardia (RR=0.27; 95% CI [0.15–0.46]; p<0.001). Serious adverse events did not differ between strategies (RR=0.63; 95% CI [0.33–1.23]; p=0.176), nor were there notable differences in all-cause or cardiovascular mortality, cardiovascular or VA-related hospitalizations.
Conclusions
In patients with ICM and an ICD treated for secondary VA prevention, VTA provides superior efficacy to AAD therapy—particularly in reducing appropriate ICD shocks, HF worsening, and undetected ventricular tachycardia episodes (below ICD detection limit)—with similar safety. No significant benefit was observed for ES, overall VA recurrence, mortality or hospitalization outcomes.