How should I approach the investigation of a patient with a first episode of ventricular tachycardia in the context of underlying heart disease?

Approach to investigating a first episode of ventricular tachycardia (VT) in a patient with underlying heart disease:

• Urgent specialist cardiovascular assessment: Refer the patient urgently for specialist cardiovascular assessment, ideally within 24 hours, due to the high risk associated with VT and underlying structural heart disease ¹.
• Detailed clinical history and examination: Reassess the patient’s detailed history including any previous syncopal or arrhythmic events, family history of sudden cardiac death or inherited cardiac conditions, current medications, and perform a full cardiovascular examination including vital signs and lying/standing blood pressure if appropriate ¹.
• 12-lead ECG: Record and carefully interpret a 12-lead ECG to identify conduction abnormalities, QT interval abnormalities, ventricular arrhythmias, or other relevant changes ¹.
• Cardiac imaging: Perform cardiac imaging (e.g., echocardiography) to assess the extent and nature of structural heart disease, as this will guide further management and risk stratification ¹.
• Ambulatory ECG monitoring: Consider ambulatory ECG monitoring (Holter or event recorder) to detect arrhythmias and correlate symptoms, especially if VT is suspected to be intermittent ¹.
• Exclude other causes: Investigate for other potential causes or contributors such as electrolyte imbalances, ischemia, or drug effects ¹.

This structured approach ensures timely diagnosis and management of VT in the context of underlying heart disease, reducing the risk of sudden cardiac death and guiding appropriate treatment.