Cardiac Rhythm Management

When I was cardiology registrar, drugs available for rhythm management were digoxin, quinidine and procaineamide.  During my years as a cardiologist, noteable additions were amiodarone, flecainide and sotalol.
One recollection that I have is the recognition of the entity rate-related cardiomyopathy.  Two memorable patients were:

a) B.B., a 58yr old barrister, presented with dilated cardiomyopathy, cardiac failure and atrial fibrillation.  I attributed his disease, probably erroneously, to excess alcohol consumption.   Eventually he developed episodes of ventricular tachycardia and was given amiodarone.   Not only did this prevent recurrences of VT, but it also resulted in unexpected reversion to sinus rhythm and subsequent 'disappearance' of his cardiomyopathy!

b) J.D., a 25yr old man, presented with a largely regular tachycardia of around 140/min, revealed on ECG to be bidirectional ventricular tachycardia with occasional normal sinus beats interspersed.   He claimed that his heart rate had "always been at this level".  The echocardiogram showed gross cardiac dilatation with impaired LV and RV function.   He returned to his native UK soon after and was given amiodarone which reverted the tachycardia to SR.   There was return of cardiac size and function to normal.

Defibrillation and cardioversion

Cardiac pacing

Implantable defibrillators

Percutaneous radiofrequency ablation - see Electrophysiology