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Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction
Study Questions:
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)?
Methods:
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.
Results:
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).
Conclusions:
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%.
Perspective:
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.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Sleep Apnea
Keywords: Dementia, Life Expectancy, Heart Failure, Ventricular Dysfunction, Left, Hospitalization, Death, Sudden, Cardiac, Defibrillators, Implantable, Primary Prevention
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