Selection of Antiarrhythmic Therapy: ESVEM in Focus and in Context

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The recently published electrophysiologic study vs eletrocardiographic monitoring (ESVEM) results have engendered considerable debate. In this review, the ESVEM results and conclusions will be examined in the contest of both previous and contemporary research. Data on the natural history of ventricular tachycardia/fibrillation suggest the 2-yr probability of all recurrences and fatal recurrences in the absence of treatment are 50% and 25% respectively. Early studies suggest substantial improvement in these results when individualized therapy is selected by either the ambulatory ECG/exercise tolerance test (AECG/ETT) approach or the programmed electric stimulation (PES) approach. However, ESVEM reported little improvment over historic controls using either of those approaches of the two techniques suggests clear superiority of the PES approach. A previous, small randomized study also concluded that the PES approch was superior. The anomalous findings of ESVEM might reflect their study of drug-resistant patients using less demanding definitions for prediction of drug efficacy. Nevertheless, ESVEM showed an advantage of the PES approach in an intertion-to-treat analysis using total mortality as the patients with ischemic heart disease should be aggressively revascularized, that the PES approach should be used initially but should be limited to no more than three drug trials, and that nonsuppressed patients should be expediently stratified no other effective therapies such as empiric amiodarone or implantable cardioverter-defibrillators.

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