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(Circulation. 2001;104:1564.)
© 2001 American Heart Association, Inc.

Clinical Cardiology: New Frontiers

Primary Prevention of Sudden Death With Implantable Defibrillator Therapy in Patients With Cardiac Disease

Can We Afford to Do It? (Can We Afford Not To?)

Derek V. Exner, MD, MPH; George J. Klein, MD; Eric N. Prystowsky, MD

From the Cardiovascular Research Group, University of Calgary, Calgary, Canada (D.V.E.); the Division of Cardiology, University of Western Ontario, London, Canada (G.J.K.); and Clinical Electrophysiology Laboratory, Northside Cardiology, St Vincent Hospital, Indianapolis, Ind (E.N.P.).

Correspondence to Derek V. Exner, MD, 3330 Hospital Dr NW, Room G208, Calgary, AB, Canada T2N 4N1. E-mail exner@ucalgary.ca

Key Words: cardiac arrest • cost-effectiveness • heart failure • myocardial infarction • prevention

	Introduction

 
Sudden cardiac death (SCD) is a major public health problem in North America, responsible for approximately 400 000 deaths annually.^1,2 Most episodes of SCD in ambulatory populations result from ventricular tachyarrhythmias,³ whereas bradyarrhythmias may be important in some populations, notably hospitalized patients with advanced heart failure⁴ (Figure 1). A prior article in this series by Zipes and Wellens² provides a detailed review of the pathogenesis of SCD, its underlying causes, and treatment strategies.

View larger version (24K): [in this window] [in a new window]   Figure 1. Mechanisms of SCD in ambulatory persons. Most SCDs result from ventricular fibrillation. VT, bradyarrhythmias, and other mechanisms account for the remainder.

ICD Therapy
The availability of a therapy that reliably terminates the vast majority of life-threatening tachyarrhythmic and bradyarrhythmic events has tremendous clinical appeal. The implantable cardioverter defibrillator (ICD) represents such a therapy. Despite its appeal, the ICD is imperfect. Currently, systems are costly, have a limited life expectancy, and are subject to complications in the long term.^5,6 Furthermore, many patients at risk for SCD are at risk of dying from causes that the ICD would not alter. The impact of ICD shocks also merits consideration. Evidence links multiple shocks with myocardial injury⁷ and fibrosis,⁸ and sporadic shocks are associated with significant, independent reductions in quality of life. Compared with patients not having shocks, patients in the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial who had 1 shocks in the initial year of follow-up had significant declines in self-perceived physical functioning and mental well-being, independent of ejection fraction (EF), social circumstances, and medication use. The reduction . . . [Full Text of this Article]

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