Implantable defibrillators are preferable to pharmacologic therapy for patients with ventricular tachyarrhythmias: an...

Despite their intuitive appeal, implantable cardioverter defibrillator s (ICDs) will require testing in randomized studies to establish their relative value as compared with antiarrhythmic drugs in patients with life-threatening ventricular tachyarrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]). In these studies, only total mortality is an acceptable primary end point. Lessons from recent drug studies (CAST, ESVEM, CASCADE) have shown that class-III/beta-receptor antagonist therapy is superior to class-I drugs selected by electrophysiologic or Holter monitor testing. Thus, sotalol or amiodarone should now be considered first-line drugs for VT/VF therapy. Advantages of contemporary drug therapy for VT/VF include wide experience among clinicians, progressively better drugs, lower cost, universal availability, greater flexibility in use (easy to start, titrate, and stop), ability to suppress (not just terminate) events, and favorable effect on disease progression (eg, beta-blockade effects in cardiomyopathy and ischemic heart disease). Recent matched observational studies and a small randomized experience (CASH) suggest near equivalence in total mortality in ICD and drug-treated groups. Until or unless modified by the results of large, ongoing, randomized trials (AVID, CIDS), contemporary antiarrhythmic drug therapy has much to be recommended as first-line, standard treatment for patients with VT/VF. Even in patients receiving ICDs, added drug therapy is frequently indicated.