Should Patients with Nonischemic Heart Failure Receive an ICD?

August 27, 2016

Should Patients with Nonischemic Heart Failure Receive an ICD?

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Implantable cardioverter–defibrillator therapy significantly reduced the risk for sudden cardiac death, but not enough to yield an overall survival benefit over usual care.

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

U.S. and European heart failure (HF) guidelines strongly recommend considering implantable cardioverter–defibrillator (ICD) therapy for severe left-ventricular systolic dysfunction (LVSD), regardless of the cause. However, evidence for an ICD-related survival benefit is confined largely to LVSD that is related to coronary artery disease, with some data suggesting a benefit when LVSD has a nonischemic cause (N Engl J Med 2005; 352:225).

In a partly industry-funded trial, researchers randomized 1106 symptomatic patients (median age, 64; 73% men) with nonischemic HF (LV ejection fraction ≤35%) and an elevated N-terminal pro–brain natriuretic peptide level to receive an ICD or usual care. Of the ICD group, 58% received concomitant cardiac resynchronization therapy. Nearly all patients in both groups received evidence-based medical therapies. Median follow-up was 68 months.

All-cause mortality incidence was statistically similar in the two groups (ICD, 21.6%; usual care, 23.4%), although ICD therapy had a significant survival benefit in patients younger than age 59. Sudden cardiac death (SCD) was significantly less common with an ICD than with usual care (4.2% vs. 8.3%), but not enough to show an advantage in cardiovascular death overall. Of the ICD group, 11.5% received appropriate shocks, 5.9% received inappropriate shocks, 15.3% needed a battery replacement, and 5.4% had the device permanently removed or deactivated because of infection or patient preference.

Comment

Among patients with nonischemic LVSD who received contemporary, evidence-based HF therapy, ICD implantation reduced SCD risk, but not enough to yield an overall survival benefit. This trial's relatively low incidence of SCD certainly reflects more-pervasive use of evidence-based medical therapies. Given the risks of ICD-related complications, infection, and inappropriate shocks, these data should be used to support shared decision making between physicians and their patients with nonischemic LVSD. As the editorialist notes, the findings may prompt clinical trials of ICDs in even higher-risk populations who receive evidence-based medical therapy.

Editor Disclosures at Time of Publication

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Grant / Research support National Heart, Lung, and Blood Institute; American College of Cardiology; Patient-Centered Outcomes Research Institute; John. A. Hartford Foundation Editorial boards Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American College of Cardiology (Chief Science Officer, National Cardiovascular Data Registries; Member, Board of Trustees); American Heart Association (Immediate Past Chair, Council on Quality of Care and Outcomes Research); American Board of Internal Medicine (Member, Cardiology Board)

Citation(s):

Reader Comments (2)

ALESSANDRO MILIA Resident, Internal Medicine

An ICD it's recommended only if the EF it's below 35% instead EB medical therapy..it's intresting to know the EF of the population

victor kantariya Physician, Family Medicine/General Practice

Wearable cardioverter defibrillator a safe alternative for high-risk patients. Dr. Victor-Kantariya ,MD

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