Patient barriers to implantable cardioverter defibrillator implantation for the primary prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction

INTRODUCTION

Device therapy is efficacious in preventing sudden cardiac death (SCD) in patients with reduced ejection fraction. However, few who need the device eventually opt to undergo implantation and even fewer reconsider their decisions after deliberation. This is due to many factors, including unresolved patient barriers. This study identified the factors that influenced patients' decision to decline implantable cardioverter defibrillator (ICD) implantation, and those that influenced patients who initially declined an implant to reconsider having one.

METHODS

A single-centre survey was conducted among 240 patients who had heart failure with reduced ejection fraction and met the ICD implantation criteria, but had declined ICD implantation.

RESULTS

Participants who refused ICD implantation were mostly male (84%), Chinese (71%), married (72%), currently employed (54%), and had up to primary or secondary education (78%) and monthly income of < SGD 3,000 (51%). Those who were more likely to reconsider their decision were aware that SCD was a consequence of heart failure with reduced ejection fraction, knowledgeable of the preventive role of ICDs, currently employed and aware that their doctor strongly recommended the implant. Based on multivariate analysis, knowledge of the role of ICDs for primary prophylaxis was the most important factor influencing patient decision.

CONCLUSION

This study identified the demographic and social factors of patients who refused ICD therapy. Knowledge of the role of ICDs in preventing SCD was found to be the strongest marker for reconsidering ICD implantation. Measures to address this information gap may lead to higher rates of ICD implantation.

Long-term follow-up of prophylactic implantable cardioverter-defibrillator-only therapy: comparison of ischemic and nonischemic heart disease

BACKGROUND

The benefits of primary prophylactic implantable cardioverter-defibrillators (ICDs) are actually debated, as some drawbacks become more apparent and as the natural history of cardiac disease seems to improve. Therefore, contemporary follow-up data of non-trial populations treated according to current guidelines remain necessary. The aim of this study was to evaluate mortality and the occurrence of ICD interventions in patients with coronary artery disease (CAD) and dilated cardiomyopathy (DCM) who received in the recent era a primary prophylactic ICD without resynchronization therapy.

HYPOTHESIS

Survival and event-free rates from appropriate ICD therapy are different between ischemic and nonischemic ICD patients.

METHODS

Prospective cohort study of 427 consecutive primary prevention ICD patients with ischemic or nonischemic heart disease, excluding patients with resynchronization.

RESULTS

Ischemic heart disease was present in 290 patients (68%), nonischemic heart disease in 137 patients (32%). During a median follow-up of 31 months (interquartile range [IQR] 15-45 months), 30 patients (7%) died. Mortality was not different in both disease categories. The incidence of appropriate ICD interventions was similar in CAD and DCM (23% vs 21%). Appropriate ICD intervention occurred more frequently in patients with atrial fibrillation (29% vs 19%). Inappropriate ICD intervention occurred in 11% of patients.

CONCLUSIONS

The clinical course of ischemic and nonischemic heart disease patients treated with a primary prophylactic ICD is similar with respect to mortality and to appropriate and inappropriate ICD interventions, in spite of a younger age at baseline of the DCM patients.

Device therapy for the management of cardiac tachyarrhythmias

Implantation of devices that can terminate cardiac arrhythmias has increased rapidly over recent years. This article looks at the evidence base for using such devices in the primary and secondary prevention of sudden arrhythmic death, discusses who should have a device and examines the issues surrounding implantation. Recent advances in technology and the future direction of therapy are also reviewed.

[The patient with chronic heart failure]

An expansion of the indications for the implantation of defibrillators (ICD) has not occurred as such in recent years. Nevertheless, an increase in the number of implantation figures can be expected due to the aging population and an increasing recruitment of undersupplied regions in upcoming years. Although the first defibrillator was implanted over 20 years ago in Germany and that ICD therapy is considered as the medical standard in secondary and primary prophylaxis, there are still basic questions that can only be prospectively clarified: (1) when is the right point in time for ICD implantation? (2) Can predictors, especially those with a negative predictive value, be used to exclude patients from ICD therapy? (3) Should risk stratification, which documents the current risk for a single point in time during the illness like a snapshot, more strongly reflect the development over time of the risk? In this case, it is likely that a rethinking of risk stratification, in general, to risk stratification in the sense of observation would be necessary. An adjuvant therapy in the sense of ablation of ventricular tachycardia (VT) or antiarrhythmic therapy for primary prevention of frequently occurring episodes seems to be advised based on current data. However, the right point in time for a complementary intervention is still not clear.