Perspective:

All studies on the use of WCD, except the VEST trial, are observational studies, and many demonstrate poor methodology, selection bias, and confounding. VEST is the only randomized controlled trial evaluating the benefit of WCD in patients post-myocardial infarction and ejection fraction ≤35% as compared with medical therapy alone. It reported no difference in sudden cardiac death mortality, a scaled down primary endpoint from the original all-cause mortality. Current guidelines give a Class IIa recommendation for the use of WCD in secondary prevention when implantable cardioverter-defibrillator removal is required and a Class IIb recommendation for all other scenarios, including primary prevention in individuals considered at high risk. The current analysis reminds us that the vast majority of the studies do not provide rigorous evidence in favor or against the use of the WCD. Current prescription of WCD in primary prevention is not a reflection of the body of evidence, but rather, as the authors point out, the expression of finality of sudden death.