Is Programmed Stimulation of Value in Predicting the Long-Term Success of Antiarrhythmic Therapy for Ventricular Tachycardias?

We studied the value of programmed stimulation in assessing the efficacy of antiarrhythmic agents in 52 patients with sustained ventricular tachycardia. All patients in this nonrandomized study had ventricular tachycardia inducible by programmed stimulation and also had frequent ventricular premature complexes (3=30 per hour) on Holter-monitor recordings before therapy. The efficacy of antiarrhythmic agents was assessed by both programmed stimulation and Holter recordings during serial drug testing. A regimen was deemed effective according to the programmed-stimulation criteria in 25 patients (Group 1). Twenty-seven patients in whom tachycardia could still be induced during programmed stimulation despite extensive drug trials were discharged on a regimen that caused a marked reduction of ventricular premature complexes according to Holter monitoring (Group 2). In 23 patients no effective drug regimen was identified by either set of efficacy criteria, and these patients were excluded from the present analysis. Follow-up lasted 18.6±13.9 months. Rates of arrhythmia-free survival at 12 and 24 months were 88 percent and 72 percent, respectively, in Group 1 and 84 percent and 75 percent in Group 2 (P = 0.637). We conclude that demonstration of antiarrhythmic efficacy by programmed stimulation predicts a good clinical outcome, that inefficacy as shown by the programmed-stimulation protocol used in this study may not preclude a good outcome if there is a marked reduction of spontaneous ventricular premature complexes on Holter monitoring, and that randomized trials should be conducted to validate the results of this observational study. (N Engl J Med 1986; 315:356–62.), BOTH programmed stimulation^{1 2 3 4 5 6} and Holter monitoring^{7 8 9 10} are widely used in the management of malignant ventricular arrhythmias. Both methods are reported to be highly predictive in assessing the efficacy of an antiarrhythmic regimen (with the possible exception of treatment with amiodarone^11,12) in patients with recurrent ventricular tachycardia or ventricular fibrillation.^{1 2 3 4 5 6 7 8 9 10} Although one might expect concordance between programmed stimulation and Holter monitoring in evaluating an antiarrhythmic regimen, the results of these methods are frequently discordant.^13,14 A regimen is more likely to be considered effective as indicated by Holter monitoring than by programmed stimulation.^13,14 This suggests that Holter monitoring that indicates efficacy….