Yes, I was speaking of critically ill patients with advanced heart failure. Sorry. My viewpoint is colored by my experience, just like yours.
Ibutilide is wonderful in an EP lab, but do you really want a first year medical resident ordering it and overseeing its use overnight in an ICU? I believe only our EP attendings are even allowed to place orders for Ibutilide at our institution, given that it carries a black box warning and 2.5% of those treated will develop Torsades.
I wouldn't accept that a relatively young and healthy patient is having prolonged periods of ventricular bigeminy, esp associated with ANY symptoms. If we're talking outpatients and Holter monitors, which I somehow missed the first time around, I'd be looking for causes in their lifestyle. In the hospital setting, we control quite a few variables. In the real world, your patients are smoking cigarettes, using cocaine and other drugs, drinking 15 shots of espresso a day, mixing up their medications, being dehydrated, eating poorly or drinking ETOH causing electrolyte imbalances, etc. There are a TON of variables to consider here before we start talking about one, definite course of treatment. I'm not saying I wouldn't do any further workup of an outpatient, but I'd be putting it in context and discussing lifestyle modifications, especially in a hemodynamically stable patient without significant symptom burden.
So, I don't disagree with you, for the subset of patients who require EP involvement, and have an electrical conduction issue of unclear etiology. Ablation, Ibutilide, these are good options there.