EDITORIAL
Sudden cardiac death and heart failure: can we make a difference? recent publication of a number of large randomised clinical zAIith the trials LV function it is of interest in with a
device depressed patients to establish the current position of device therapy in patients with heart failure (HF). Despite optimal medical treatment, heart failure has a poor prognosis with a five-year mortality of approximately 50% following the diagnosis.' Frequently death is sudden and unexpected and even though other causes may contribute to the high sudden death rate, death is usually caused by malignant ventricular arrhythmias. Although, in absolute numbers, more patients with advanced stages of disease will die suddenly, the proportion of sudden death is even higher in the group of patients with moderate symptoms (New York Heart Association class I and II heart failure symptoms, 64% of all deaths) compared with the group with advanced symptoms (NYHA class III and IV, 59 and 33% of all deaths, respectively).2 It is thus a challenging task to prevent sudden death in HF patients as this may have a beneficial effect on total mortality. Due to their well-established inefficacy or even proarrhythmogenic effects most antiarrhythmic drugs, with the possible exception of amiodarone, can not be used to prevent sudden death in HF patients.3-9 Amiodarone, as shown in a meta-analysis including 6500 patients from 13 trials, may have a limited overall mortality benefit of 10 to 15%.9 However, amiodarone is also associated with worsening heart failure symptoms, most likely caused by amiodarone-induced delayed ventricular activation resulting in increased LV dyssynchrony.'0 As sudden death in HE patients is caused by a malignant ventricular arrhythmia in the majority of cases, implantation of a defibrillator (ICD) may lower mortality. Efficacy of lCD therapy has been well established both in secondary and primary prevention trials."1-6 Even in the absence ofsymptomatic ventricular arrhythmias, implantation of an ICD improves survival in ischaemic cardiomyopathy patients (LVEF
Sudden cardiac death and heart failure: can we make a difference? recent publication of a number of large randomised clinical zAIith the trials LV function it is of interest in with a
device depressed patients to establish the current position of device therapy in patients with heart failure (HF). Despite optimal medical treatment, heart failure has a poor prognosis with a five-year mortality of approximately 50% following the diagnosis.' Frequently death is sudden and unexpected and even though other causes may contribute to the high sudden death rate, death is usually caused by malignant ventricular arrhythmias. Although, in absolute numbers, more patients with advanced stages of disease will die suddenly, the proportion of sudden death is even higher in the group of patients with moderate symptoms (New York Heart Association class I and II heart failure symptoms, 64% of all deaths) compared with the group with advanced symptoms (NYHA class III and IV, 59 and 33% of all deaths, respectively).2 It is thus a challenging task to prevent sudden death in HF patients as this may have a beneficial effect on total mortality. Due to their well-established inefficacy or even proarrhythmogenic effects most antiarrhythmic drugs, with the possible exception of amiodarone, can not be used to prevent sudden death in HF patients.3-9 Amiodarone, as shown in a meta-analysis including 6500 patients from 13 trials, may have a limited overall mortality benefit of 10 to 15%.9 However, amiodarone is also associated with worsening heart failure symptoms, most likely caused by amiodarone-induced delayed ventricular activation resulting in increased LV dyssynchrony.'0 As sudden death in HE patients is caused by a malignant ventricular arrhythmia in the majority of cases, implantation of a defibrillator (ICD) may lower mortality. Efficacy of lCD therapy has been well established both in secondary and primary prevention trials."1-6 Even in the absence ofsymptomatic ventricular arrhythmias, implantation of an ICD improves survival in ischaemic cardiomyopathy patients (LVEF
