Cardiology and Arrhythmology, Georges Pompidou Hospital, René Descartes University, 20 rue Leblanc, Paris, France.
Europace. 2012 Nov;14 Suppl 5:v125-v128. doi: 10.1093/europace/eus283.
The strategy of sudden cardiac death prevention by implantable cardioverter defibrillator, in primary prevention, is mainly based on the value of ejection fraction. That means that the approach is not really patient specific. A lot of implanted patients will not receive any shock. The implantation of large categories of patients is interesting on a global therapeutical point of view but, when considering the economical aspects, it would be more useful to have better selection criteria in order to obtain a more patient-specific approach, avoiding implanting patients who will never receive shocks. The parameters commonly used to select patients for implantations have a good negative predictive value but a low positive predictive value. Concerning atrial fibrillation the approach is quite different. Antiarrhythmic drug treatment has shown many limitations. Antiarrhythmic drugs are useful and safe in atrial fibrillation patients only if the contra-indications are strictly respected. The main difficulty concerns patients with both heart failure and atrial fibrillation. The story of Dronedarone development is illustrative of the necessity of a patient-specific approach in the treatment strategy of atrial fibrillation. The ATHENA trial made with Dronedarone showed a benefit in patients with underlying heart disease but no patient with advanced cardiopathy was included in the study. On the contrary, the PALLAS trial has clearly shown that the drug is contra-indicated in patients with any type of heart failure. In atrial fibrillation, a patient-specific approach is mandatory. This review illustrates the dichotomy of the two different approaches.
植入式心脏复律除颤器预防心源性猝死的策略，在一级预防中，主要基于射血分数的价值。这意味着这种方法并不是真正针对患者个体的。很多植入患者不会接受任何电击。从全球治疗的角度来看，植入大量类别的患者是有趣的，但从经济角度考虑，最好有更好的选择标准，以获得更针对患者个体的方法，避免植入永远不会接受电击的患者。用于选择患者植入的参数通常具有良好的阴性预测值，但阳性预测值较低。对于心房颤动，方法是不同的。抗心律失常药物治疗已经显示出许多局限性。抗心律失常药物在严格遵守禁忌症的情况下，仅在心房颤动患者中是安全有效的。主要困难涉及同时患有心力衰竭和心房颤动的患者。曲多酮开发的故事说明了在心房颤动的治疗策略中需要针对患者个体的方法。用曲多酮进行的 ATHENA 试验显示了患有基础心脏病的患者的获益，但研究中没有包括任何类型的晚期心脏病患者。相反，PALLAS 试验清楚地表明，该药物在任何类型的心力衰竭患者中均被禁用。在心房颤动中，针对患者个体的方法是强制性的。这篇综述说明了两种不同方法之间的二分法。
