A brief history of sudden cardiac death and its therapy.

At the end of the 19th century, there was both experimental and clinical evidence that coronary artery obstruction causes ventricular fibrillation and sudden death and that fibrillation could be terminated by electric shocks. The dominant figure at that time was McWilliam, who in 1923 complained that "little attention was given to the new view for many years." This remained so for many decades. It was not until the 1960s that the medical profession became aware of the magnitude of the problem of sudden death and began to install coronary care units where arrhythmias could be monitored and prompt defibrillation could be delivered. This approach was pioneered by Julian in 1961. Milestones that allowed this development were open-chest defibrillation by Beck, closed-chest defibrillation by Zoll, cardiac massage by Kouwenhoven et al., and development of the DC defibrillator by Lown. In 1980, Mirowski et al. implanted the first implantable cardioverter defibrillator (ICD) in a patient. Thereafter, the use of the ICD increased exponentially. Several randomized trials, largely in patients with coronary artery disease and left ventricular dysfunction or in patients with documented lethal arrhythmias, showed beyond doubt that the ICD is superior to antiarrhythmic drug therapy in preventing sudden death, although a number of trials showed no effect. Trials on antiarrhythmic drugs were disappointing. Sodium channel blockers and "pure" potassium channel blockers actually increase mortality, calcium channel blockers have no effect, and, although amiodarone reduces arrhythmic death, it had no effect on total mortality in the 2 largest trials. Only the beta-blockers have been proven to reduce the incidence of sudden death, but their effect appears not to be related to the suppression of arrhythmias but rather to the reduction in sinus rate. Drugs that prevent ischemic events, or lessen their impact, such as anticoagulants, statins, angiotensin-converting enzyme inhibitors, and aldosteron antagonists, all reduce the incidence of sudden death.

History of cardiac rhythm disorders.

The history of cardiac rhythm disorders including antiarrhythmic drugs and electrotherapeutical tools is long and fascinating. In the beginning, there was not simply the anatomy and physiology of the heart, but also analysis of the pulse, which indicates the activity of the heart. Thus, like any other field of medicine, the study of arrhythmias has a distinctive past. Our current level of knowledge is not the result of a straight, linear progression any more than there is a static, established, monolithic body of thought dominating this field. Instead, our knowledge of arrhythmias today is the result of many competitive, sometimes serendipitous, scientific realizations, of which a few proved useful enough to pursue and eventually led to real advancements. Looking at the worldwide development of rhythmology it can be said that considerable contributions came from Germany in the last few centuries. Arrhythmology--past, present and future--includes clearly German investigators as pioneers of the field. The growing clinical importance of electric cardiac stimulation has been recognized and renewed as Zoll in 1952 described a successful resuscitation in cardiac standstill by external stimulation. The concept of a fully automatic implantable cardioverter-defibrillator system for recognition and treatment of ventricular flutter/fibrillation was first suggested in 1970. The first implantation of the device in a human being was performed in February 1980. By early 1997, 17 years after the first human implantation more than 100,000 ICD systems had been implanted worldwide. Further developments concern new pharmacological compounds, modern cardioverter-defibrillators, radiofrequency ablation, particularly pulmonary vein ablation in atrial fibrillation, innovative pacemakers including preventive pacing techniques, probably laser therapy and perhaps the automatic implantable pharmacological defibrillator. The advances in the field of therapeutic application of pharmacologic and electrical means as well as alternative methods will continue as rapidly as before in order to give us further significant aid in taking care of the patient.