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(Circulation. 2007;116:1204-1212.)
© 2007 American Heart Association, Inc.

Controversies in Cardiovascular Medicine

Response to Almendral and Josephson

David J. Callans, MD

The elegant article by Almendral and Josephson makes many important points, but I am concerned about 2 of their assumptions. The first is keeping score by means of arrhythmic instead of total mortality. All major implantable cardioverter-defibrillator (ICD) trials have used the metric of total mortality for the following reasons: Even with a blinded review panel, the treachery of assigning a specific cause of death is well known; this problem is greatly magnified when investigators are directly caring for the patients in the trial. In addition, the concept of competing mortality risk, in which a patient is saved from sudden death only to succumb to heart failure death soon after, is not compelling. Finally, it has been demonstrated (as in the Defibrillators in Acute Myocardial Infarction Trial [DINAMIT]) that ICDs may have a negative effect on nonsudden mortality despite reducing arrhythmic death. Second, although I share their enthusiasm for catheter ablation, it is not clear that this strategy protects patients against sudden death. It may be that such patients have a low incidence of sudden death, but it does not necessarily follow that this is an effect of ablation, given the incidence of recurrent ventricular tachycardia. However, most patients who present with tolerated ventricular tachycardia meet the criteria for primary-prevention ICD therapy. Does it make any sense to worry less about patients who present with sustained ventricular tachycardia than about those who have never had an arrhythmia? This controversy will probably not last forever. Progress in ICD and ablation therapy and our understanding of the pathophysiology of ventricular arrhythmias will eventually clarify the situation. Until then, I will do whatever I can to keep my patients as safe as possible.

	Footnotes

 
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

Guest Editor for this article was Douglas P. Zipes, MD.

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Almendral, J. Articles by Josephson, M. E. Search for Related Content PubMed PubMed Citation Articles by Almendral, J. Articles by Josephson, M. E. Related Collections Ablation/ICD/surgery