New directions in cardiac arrhythmia management: present challenges and future solutions.

Cardiac arrhythmias are a major contributor to population morbidity and mortality. Enormous advances in arrhythmia management have occurred over the 60 years since the founding of the Montreal Heart Institute, but important challenges remain. The purpose of this article is to identify the areas of cardiac arrhythmia therapy that need improvement and to discuss the evolving approaches that promise solutions. Challenges in diagnosis, detection, and risk-stratification include difficulties in separating benign from high-risk syncope and pinpointing the underlying causes, the detection of silent atrial fibrillation in patients at risk of stroke, and inadequate identification of sudden-death risk. Implantable devices are limited by the need for battery and device replacements, device complications like infection and dysfunction, and lead complications like fracture, infection, or displacement. Antiarrhythmic drug therapy, although widely used, is plagued by a very limited range of available agents, supply issues, insufficient efficacy, and significant adverse effect risk. Health economic concerns include the high cost of new technologies, challenges in establishing cost effectiveness, and restrictive practices of government or third-party payers. Major improvements in arrhythmia management can be expected from new discoveries and technological developments in genetics, innovative diagnostic tools for arrhythmia monitoring, imaging and analysis, new approaches to antiarrhythmic drug development, biological therapies, and continuing improvement in implantable device technology like further miniaturization, leadless technology, and use of novel energy sources. As exciting as the developments in arrhythmia management have been in the past, we can look forward to exponential improvement in our ability to manage arrhythmia patients in the near future.