Referring Physicians’ Discordance With the Primary Prevention Implantable Cardioverter-Defibrillator Guidelines: A National Survey

Jun 29, 2012
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Authors:
Castellanos JM, Smith LM, Varosy PD, et al.
Citation:
Heart Rhythm 2012;9:874-881.
Summary By:
Fred Morady, MD, FACC

Study Questions:

How often do referring physicians adhere to guidelines for therapy with an implantable cardioverter-defibrillator (ICD) for the primary prevention of sudden cardiac death (SCD)?

Methods:

A 34-item questionnaire dealing with primary prevention (PP) guidelines and practice patterns was mailed to 3,000 family practitioners, internists, and cardiologists.

Results:

The respondents consisted of 473 family practitioners, 437 internists, and 468 general cardiologists. Twenty-eight percent of respondents (including 7% of cardiologists) do not refer patients specifically for a PP ICD. Fifteen percent of respondents opined that a PP ICD never is indicated in the absence of ventricular arrhythmias. Thirty-six percent of respondents felt that a PP ICD is indicated when the ejection fraction is >40%. Twenty-five percent of respondents refer patients for a PP ICD within 40 days of a myocardial infarction. The respondents reported referring 85% of patients whom they believe are appropriate candidates for a PP ICD. The most common reasons for not referring suitable candidates were patient preference and concerns about device infection and painful ICD shocks.

Conclusions:

When asked questions regarding PP ICDs, approximately one-third of a random sample of referring physicians provided answers that were inconsistent with practice guidelines.

Perspective:

Prior studies have indicated that a sizeable proportion of patients who qualify for a PP ICD, particularly women and minorities, never receive a device. The specific reasons for this have been unclear. The results of the present study suggest that underutilization of PP ICDs often is due to patient preference. Discordance with guidelines would seem to often result in over-referral for a PP ICD, not under-referral. Nevertheless, the study emphasizes the need for better education of referring physicians.

Keywords: Myocardial Infarction, Tachycardia, Ventricular, Shock, Heart Rate, Death, Sudden, Cardiac, Defibrillators, Implantable, Primary Prevention


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