Drugs versus devices: contemporary practice in light of contemporary trials

In years past, the secondary prevention of life-threatening ventricular arrhythmias was limited to empiric drug therapy. In close temporal proximity to the birth of electrophysiologic study-guided treatment strategies to manage these arrhythmias, devices to convert arrhythmias were envisioned and designed. Now, advanced generation implantable defibrillators provide synchronized, low-energy cardioversion, antitachycardia pacing, and pacing support for bradycardia. Over the past decade and half, this technology that was once applied as a therapy of last resort has evolved and emerged as a therapy of first choice. Recently, however, enthusiasm for drug treatment strategies has also increased, especially the use of amiodarone. Most experts now agree that drug therapy chosen by electrophysiologic study guidance provides superior survival compared to the empiric use of Class I drugs, as long as a drug that suppresses arrhythmia inducibility is found. The empiric use of amiodarone and beta blockers may also improve outcome. This review examines some of the recent clinical trials utilizing pharmacologic and nonpharmacologic methods. The importance of ongoing and future clinical trials is emphasized.