We describe a patient with ischemically mediated sustained monomorphic ventricular tachycardia occurring at rest and resistant to treatment with intravenously administered procainamide. Percutaneous transluminal coronary angioplasty was initially successful, but rest angina and ventricular tachycardia, resistant to procainamide therapy, recurred 2 weeks later and responded to aggressive anti-ischemic medical therapy. We suggest that anti-ischemic medication may be of benefit in patients with malignant ventricular arrhythmias precipitated by spontaneous myocardial ischemia.