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This editorial refers to “Response of programmed electrical stimulation and clinical outcome in cardiac arrest survivors receiving randomized assignment to implantable defibrillator or antiarrhythmic drug therapy”1 by Cappato et al. on page 642.The chances of surviving sudden cardiac death (SCD) are low (5–60%)1 and the recurrence rate is high (40% in the following 2 years). Secondary prevention in SCD-survivors is mandatory. SCD remains the “challenge to contemporary cardiology” as B. Lown wrote in the late 1970s.In SCD survivors the tool of choice is the implantable cardioverter-defibrillator (ICD), a crude but effective device that increases survival \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(>\) \end{document}90%.1 It prolongs survival, but also reduces the quality of life. However, in view of the 40% recurrence rate of lethal, arrhythmic events, the ICD is implanted in 60/100 patients unnecessarily!Despite the efficacy of ICD therapy, its high costs are a considerable burden for the community, making a more precise risk stratification necessary to identify patients at the highest risk of recurrence of sudden arrhythmic death among the survivors who would most benefit from ICD.A fascinating model dominated the 1980s and 1990s: the induction of sustained ventricular tachycardia and ventricular fibrillation (VT/VF) using the PVS technique was used to stratify the high-risk group that should undergo secondary prophylaxis with drugs (β-blockers, amiodarone) and/or ICD implantation.Three major randomised trials examined the efficacy of ICD therapy versus antiarrhythmic drugs for secondary prevention in SCD survivors: The antiarrhythmics versus implantable defibrillators (AVID) trial, the Cardiac Arrest Study Hamburg (CASH) and the Canadian implantable defibrillator study (CIDS). All these trials used all-cause mortality as an endpoint and … *Correspondence to: Tel.: +43-1-28802-3101; fax: +43-1-60-191-2509  E-mail address: heinrich.weber{at}wienkav.at

Treating electrical instability in sudden cardiac death survivors – are we looking at the right side of the coin?