Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction
How often do eligible patients with heart failure (HF) not receive an implantable cardioverter-defibrillator (ICD) for the primary prevention of sudden cardiac death (SCD)?
The medical records of 542 patients (median age 64 years) with HF and an ejection fraction (EF) ≤30% were reviewed in detail to determine if an ICD was implanted within 1 year of the index HF hospitalization. If an ICD was not implanted, data on contraindications (e.g., patient refusal, severe dementia, nonoptimal medical therapy, limited life expectancy) were collected.
Forty-one percent of the 542 patients did not receive an ICD. A valid contraindication was identified in the majority of these patients. Among the 542 patients, 13% of patients who were eligible did not receive an ICD despite the absence of a contraindication. The lack of ICD use was not associated with age or gender, but was associated with hospitalization on a noncardiology service (odds ratio [OR], 3.7) and lack of health insurance (OR, 3.1).
The true underutilization rate of ICDs for the primary prevention of SCD is substantially lower than the proportion of patients with HF who meet the EF criterion of ≤30%.
Prior studies have reported ICD underutilization rates as high as 30-40%. However, these studies were based largely on identification of patients with HF or prior MI who had an EF ≤30-35%. In this study, after detailed chart review, the underutilization rate fell from 41% to only 13%. However, the study was performed at a single academic center and the results may or may not be applicable to general practice.
Keywords: Dementia, Life Expectancy, Heart Failure, Ventricular Dysfunction, Left, Hospitalization, Death, Sudden, Cardiac, Defibrillators, Implantable, Primary Prevention
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