PubMed · 14068382
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E M VAUGHANWILLIAMS. 1963. FIBRILLATION.. https://doi.org/10.1016/0002-8703(63)90392-2
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BACKGROUND: Results of recent studies suggest new aspects in the concept of the management of patients with atrial fibrillation. Current trials comparing rhythm control by cardioversion followed by antiarrhythmic drug therapy with heart rate control only showed that rhythm control was not superior to rate control. SPECIAL ASPECTS OF ELECTRICAL CARDIOVERSION: However, some subgroups of patients with frequent or severe symptoms and younger patients with structurally normal hearts may benefit from cardioversion. In patients with persistent atrial fibrillation, sinus rhythm can be restored in approximately 90% by direct current transthoracic cardioversion. Transthoracic cardioversion is effective and safe, if anticoagulation is used. Attempts have been made to improve the success rate by new techniques. However, definition of subgroups and stabilization of sinus rhythm are ongoing issues of debate.
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PURPOSE OF REVIEW: Controlled trials for secondary prevention of sudden death--Antiarrhythmics Versus Implantable Defibrillators (AVID), Canadian Implantable Defibrillator Study (CIDS), and Cardiac Arrest Study Hamburg (CASH)--have been published and subanalyses of them provide useful clinical information on the outcome during the follow-up of this population. RECENT FINDINGS: Results from a meta-analysis showed a significant risk reduction (RR) of 25 to 27% of total mortality (P < 0.001) and 50 to 52% of arrhythmic death (P < 0.001). Compared with amiodarone, patients treated with an implantable cardioverter-defibrillator (ICD) in AVID had a maximal benefit in survival when the ejection fraction (EF) was between 20 and 34%. In CIDS, the group of higher risk (older than 70 years, EF less than 3.5%, and New York Heart Association class III-IV) presented a 50% RR of mortality. It has been demonstrated that the imbalance in beta-blocker use cannot explain the better survival in the ICD patients. After 3 years the recurrence of arrhythmia was 64% in the ICD group of the AVID trial. Patients enrolled after an episode of ventricular tachycardia were more likely to have appropriate therapy during follow-up. Older age, lower blood pressure, history of atrial fibrillation, diabetes, congestive heart failure, and prior pacemaker were parameters used for high-risk stratification. Conversely, inducibility of ventricular tachyarrhythmias on electrophysiology did not predict death. SUMMARY: Patients with ICD after ventricular tachyarrhythmias have a 28% RR in total mortality. Individuals with EF between 20 to 34% received the highest benefit with ICD therapy.