Relative value of exercise electrocardiography, long-term electrocardiographic monitoring and programmed electrical stimulation of the heart in the treatment of cardiac arrhythmias.

A long time ago, Sénac (1683-1770) treated palpitations with quinine. Three centuries later Wenckebach rediscovered the value of quinine in atrial fibrillation and now gets the credit for it, at least in the American literature. Life has plenty of paradoxes; the history of the treatment of arrhythmias too. Pope Clement XI (1649-1721) has become known in history for his opposition to adapting Catholic rituals to Chinese habits. He will never be credited as the man, however, who supported the first 'epidemiological' study on sudden death. It was 1705 when he ordered Lancisi to study by autopsy the cause of any unexpected death among Roman nobles. The results were rather disappointing. We have come a long way since then. While good clinical judgement and common sense remain the most important tools in the treatment of cardiac arrhythmias, technicological progress has provided us with refined techniques for studying that problem. Among them, long-term electrocardiographic monitoring, exercise testing and programmed electrical stimulation of the heart. However, and as Zipes pointed out, we are far from perfection in the treatment of cardiac arrhythmias. Whether it was Sénac or Wenckebach who first observed that quinine could change an irregular heart rhythm (atrial fibrillation) into a regular one (sinus rhythm), we are not far from their empiricism. However refined they may look, our present methods of diagnosis and treatment of arrhythmias are regrettably imperfect. These techniques have to be used carefully and rationally. Their present value and limitations will be outlined here.