HRS/ACCF/AHA Expert Consensus Statement on the Use of Implantable Cardioverter-Defibrillator Therapy in Patients Who Are Not Included or Not Well Represented in Clinical Trials

Perspective:

The purpose of this Expert Consensus Statement is to provide clinicians with guidance on the use of implantable cardioverter-defibrillator (ICD) therapy in the management of patient populations that are not represented in clinical trials. A multitude of clinical scenarios are discussed, and clinical rationale for the recommendations is offered. The following are 10 points to remember about these recommendations:

1. In patients with abnormal cardiac biomarkers that are not thought to be due to a myocardial infarction (MI), and who otherwise would be candidates for implantation on the basis of primary prevention or secondary prevention criteria, implantation of an ICD is recommended.

2. In patients who, within 40 days of an MI, require nonelective permanent pacing, who also would meet primary prevention criteria for implantation of an ICD, and for whom recovery of left ventricular (LV) function is uncertain or not expected, implantation of an ICD with appropriately selected pacing capabilities is recommended.

3. In patients who, within 40 days of an MI, develop sustained (or hemodynamically significant) ventricular tachyarrhythmias >48 hours after an MI and in the absence of ongoing ischemia, implantation of an ICD is recommended.

4. In patients who, within 40 days of an MI, present with syncope that is thought to be due to ventricular tachyarrhythmia (by clinical history, documented nonsustained ventricular tachycardia [NSVT], or electrophysiologic [EP] study), implantation of an ICD can be useful.

5. In patients who are within 90 days of revascularization and who previously qualified for the implantation of an ICD for primary prevention of sudden cardiac death, and who have undergone revascularization that is unlikely to result in an improvement in LV ejection fraction >35, and who are not within 40 days after an acute MI, implantation of an ICD can be useful.

6. In patients within 90 days of revascularization who require nonelective permanent pacing, who would also meet primary prevention criteria for implantation of an ICD, and in whom recovery of LV function is uncertain or not expected, implantation of an ICD with appropriately selected pacing capabilities is recommended.

7. In patients within 90 days of revascularization with structural heart disease and sustained (or hemodynamically significant) ventricular tachyarrhythmia that was not clearly related to acute MI or ischemia, implantation of an ICD is recommended.

8. In patients within 90 days of revascularization with syncope that is thought to be due to ventricular tachyarrhythmia (by clinical history or documented NSVT, or EP study), implantation of an ICD can be useful.

9. If recovery of LV function is unlikely, implantation of an ICD for primary prevention can be useful between 3 and 9 months after initial diagnosis of nonischemic cardiomyopathy.

10. In patients <9 months from the initial diagnosis of nonischemic cardiomyopathy who require nonelective permanent pacing, who would meet primary prevention criteria for implantation of an ICD, and recovery of LV function is uncertain or not expected, implantation of an ICD with the appropriately selected pacing abilities is recommended.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias

Keywords: Myocardial Infarction, Tachycardia, Ventricular, Secondary Prevention, Ventricular Function, Left, Cardiomyopathies, Syncope, Death, Sudden, Cardiac, Defibrillators, Implantable, Primary Prevention, Consensus


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