Treatment of Sustained Ventricular Arrhythmias: Which Therapy to Use?

During the last 10 years major advances (1-9) have occurred in pharmacologic, surgical, and electrical therapies for arrhythmias. These advances make each form of therapy an acceptable alternative in many pa-tients with ventricular arrhythmias. Physicians need to know how each form of therapy is instituted and which patients with sustained ventricular arrhythmias are ideally suited for each therapy. In addition, they should understand the benefits, risks, and potential limitations of each therapy to support the patient's participation in the decision making process when more than one treatment option appears appropriate. Although more than one dozen antiarrhythmic agents have been approved for the treatment of ven-tricular tachyarrhythmias and a similar number are in the investigational stage, selection of the best antiar-rhythmic agent remains difficult (10). No single agent appears to be distinctly superior with respect to effica-cy. Furthermore, there is no characteristic of the spon-taneous arrhythmia that generally predicts drug effica-cy. Not uncommonly, the frequency of dosing and the risks for cardiac and noncardiac toxicity become the major considerations in choosing the initial therapy (10, 11). Once a drug is selected, its efficacy needs to be as-sessed. Noninvasive assessment of drug efficacy using the abolition of ventricular ectopic activity during Holter monitoring or exercise testing to predict the likelihood of arrhythmia control appears to be inade-quate, especially for patients with life-threatening symptoms (4, 12, 13). Noninvasive testing should b