Death due to ventricular tachyarrhythmia (VT) remains an important pub
lic health problem; patients with prior myocardial infarction (MI) con
stitute the largest identifiable population for prophylactic intervent
ions. Targeting of progressively higher-risk subgroups of post-MI svrv
ivors carries inevitable tradeoffs with respect to the global impact o
f interventions on overall mortality. Therapy with aspirin, beta block
ers, and angiotensin-converting enzyme (ACE) inhibitors comprise the b
enchmark against which all additional interventions, including implant
able defibrillators, must be measured. Initial enthusiasm for empiric
amiodarone therapy has been tempered by the limited benefit demonstrat
ed in recent randomized trials. Trials of other class III antiarrhythm
ic drugs, including both d,l-sotalol and d-sotalol, have also failed t
o demonstrate survival benefit. The Multicenter Automatic Defibrillato
r Implantation Trial (MADIT) demonstrated significantly improved survi
val associated with defibrillators in a small subgroup of post-MI surv
ivors with a high short-term risk of death. The ultimate number and op
timal criteria for selection of patients who may benefit from prophyla
ctic defibrillator therapy after MI will undergo continued evolution a
s new data from current and ongoing trials become available. (C) 1997
by Excerpta Medica, Inc.