Drugs, surgery, cardioverter defibrillator: a decision based on the clinical problem

These three therapeutic options are the basis of sudden cardiac death prevention: antiarrhythmic drugs, surgery, and automatic implantable cardioverter defibrillator. Each of these treatments has specific favorable and unfavorable indications. Antiarrhythmic drugs are mainly limited by the low therapeutic profile, proarrhythmic effects, complex pharmacokinetics and pharmacodynamics, possible negative inotropic effects, and the possible change of the organic substratum. Arrhythmia surgery may be limited by the need of a highly trained center, by a relatively high perioperative mortality (up to 15%), and by limited electrophysiological and clinical indications. The implantable cardioverter defibrillator is an expensive tool with a theoretically wide range of clinical indications, with already proven efficacy in converting ventricular fibrillation to sinus rhythm but with unproven efficacy on prolonging survival because of a lack of controlled trials (which, we must admit, is also true for drugs and surgery). The results of the ongoing multicenter trials on this item will clarify this clinical point. The choice among these different therapeutic options is mainly based on hemodynamic status (ejection fraction), feasibility of a surgical treatment, and the electrophysiological characteristics of the ventricular arrhythmia.