Sudden cardiac death

This is a landmark — a 1998 Circulation review of sudden cardiac death by two titans of electrophysiology, and a document that helped shape how medicine confronts a problem that kills hundreds of thousands of Americans a year, often as the very first sign of heart disease.

Its enduring lessons: sudden cardiac death accounts for roughly half of cardiovascular mortality and most victims have underlying coronary disease; among drugs, only beta-blockers and amiodarone reduce it (some antiarrhythmics make it worse); the implantable defibrillator beats drugs for those who’ve survived a cardiac arrest; and — a “risk paradox” still central today — the small high-risk groups are easy to find but generate few total events, while the large low-risk population produces most of the deaths. The authors’ call for automated defibrillators “as common as fire extinguishers” reads as prophecy.

The practical takeaway is mostly historical now: this captured the field at the dawn of the ICD era and the public-access-defibrillation movement that followed.

We rate the evidence high for its stature: foundational, enormously cited, from the field’s leading authorities — though now over a quarter-century old, with much since (MADIT-II, SCD-HeFT, wearable defibrillators, arrhythmia genetics) built atop it. Its clinical significance is high as the framework that shaped modern sudden-death prevention, even as the specifics have advanced. A fitting capstone: the ultimate stake behind everything this library is about — preventing the heart attack you don’t see coming.