INTRODUCTION: Antiarrhythmic drugs (AADs) have traditionally been used as first-line therapy for ventricular tachycardia (VT) but are frequently associated with systemic toxicities and drug interactions. Therefore, we performed a meta-analysis comparing early catheter ablation (CA) with AAD therapy as initial treatment for VT in patients with prior myocardial infarction. METHODS AND RESULTS: PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials comparing CA vs. AAD in patients naïve to both strategies. Meta-analysis was performed using Review Manager. Three randomized trials including 618 patients were analysed. No significant differences were observed in all-cause mortality, appropriate implantable cardioverter-defibrillator (ICD) therapies (including shocks and antitachycardia pacing), ventricular arrhythmia storm, hospitalizations, or adverse events between strategies. Leave-one-out sensitivity analysis identified one trial as the primary contributor to between-study heterogeneity. CONCLUSION: Early catheter ablation provides similar efficacy to first-line antiarrhythmic drug therapy for major arrhythmic and survival outcomes, with reductions in hospitalizations and treatment-related adverse events, although largely driven by one trial. These findings support consideration of CA as a first-line therapeutic strategy in selected patients with ischaemic VT.