Revisiting ICDs for Primary Prevention in HFrEF

Abstract and Introduction

Abstract

Implantable cardioverter-defibrillators (ICDs) are recommended to reduce the risk of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). The landmark studies leading to the current guideline recommendations preceded the 4 pillars of guideline-directed medical therapies (GDMTs). Therefore, some have questioned the role of ICDs for primary prevention in current clinical practice. In this paper, the authors provide an overview of the current ICD recommendations, including the instrumental clinical trials, the risk of SCD as observed in clinical trials vs real-world scenarios, disparities in ICD use among different patient populations, the impact of contemporary GDMT on outcomes, and ongoing and future trials and methodologies to help identify patients who are at an increased risk of SCD and who may benefit from an ICD. The authors also propose a pragmatic guidance for clinicians when they engage in the shared decision-making discussions for primary ICD implantation.

Introduction

Sudden cardiac death (SCD) is a leading cause of death in the United States and worldwide, outnumbering cancer mortality. ^[1] Ventricular tachycardia (VT) and ventricular fibrillation (VF) are the most common malignant rhythms that can result in SCD. SCD has the highest incidence in patients with previous cardiac arrest and those with structural heart disease and reduced left ventricular ejection fraction (LVEF).^[2] Patients with HFrEF caused by ischemic or nonischemic cardiomyopathy (NICM) were the focus of clinical trials that proved the efficacy of implantable cardioverter-defibrillator (ICD) therapy.^[3]

Authors and Disclosures

Amin Yehya, MD, MS^a; Jose Lopez, MD^b; Andrew J. Sauer, MD^c; Jonathan D. Davis, MD^d; Nasrien E. Ibrahim, MD, MPH^e; Roderick Tung, MD^f; Biykem Bozkurt, MD, PHD^g; Gregg C. Fonarow, MD^h; Sana M. Al-Khatib, MD, MHSⁱ

From the ^aAdvanced Heart Failure Center, Sentara Heart Hospital, Norfolk, Virginia, USA; ^bDivision of Cardiovascular Disease, University of Miami Miller School of Medicine, JFK Hospital, Atlantis, Florida, USA; ^cSaint Luke’s Mid America Heart Institute, Kansas City, Missouri, USA; ^dDivision of Cardiology, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, California, USA; ^eBrigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA; ^fThe University of Arizona College of Medicine—Phoenix, Banner—University Medical Center, Phoenix, Arizona, USA; ^gDivision of Cardiology, Baylor College of Medicine, Houston, Texas, USA; ^hUCLA Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA; and the ⁱDivision of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA.

ADDRESS FOR CORRESPONDENCE: Dr Amin Yehya, Medical Director, MCS Program, Sentara Heart Hospital, 600 Gresham Drive, Norfolk, Virginia 23507, USA. E-mail: amin.yehya@yahoo.com. X handle: @AminYehyaMD.

FUNDING SUPPORT AND AUTHOR DISCLOSURES: Dr Yehya has received speaking honoraria and consulting fees from Bayer, Merck, Novo Nordisk, AstraZeneca, and scPharmaceuticals. Dr Sauer has received research funding and consulting or speaking honoraria from Amgen, Abbott, Bayer, Boston Scientific, CSL Vifor, AstraZeneca, Impulse Dynamics, Fire1, uLink, Story Health, General Prognostics, Acorai, Edwards Lifesciences, Rivus, Pfizer, 35Pharma, and Regeneron; and owns stock in ISHI, a privately held digital health company. Dr Bozkurt has received consulting fees from Abbott, Abiomed, American Regent, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cardurion, Cytokinetics, Daiichi Sankyo, Johnson and Johnson, Lantheus, Liva Nova, Merck, Regeneron, Renovacor, Respicardia/Zoll, Roche, Sanofi-Aventis, and Vifor. Dr Fonarow has received consulting fees from Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson and Johnson, Medtronic, Merck, Novartis, and Pfizer. Nasrien Ibrahim has received consulting fees from Applied Therapeutics and Cytokinetics. Dr Tung has received speaking honoraria and consulting fees from Medtronic, Abbott, Biotronik, Boston Scientific. All other authors have no relationships relevant to the contents of this paper to disclose.

Revisiting ICD Therapy for Primary Prevention in Patients With Heart Failure and Reduced Ejection Fraction

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