Abstract 2687: A Watchful Waiting Behavior is Advisable Before Implanting an ICD in Patients with Chronic Heart Failure
Aims. Current guidelines for chronic heart failure (HF) recommend implantion of an ICD in NYHA class II-III patients with an ejection fraction (EF) less than 30% who are optimized to pharmacological treatment. To test the clinical implications of such recommendations, we assessed the Val-HeFT database for the number of patients eligible for ICD implantation and their outcomes at 2 years.
Methods. Val-HeFT trial included patients with HF, NYHA class II-IV, on stable, optimized treatment for at least 1 month, with reduced EF (<40%), and left ventricular dilatation. Patients with ICD indication were selected among the 4550 patients for whom complete clinical information, an EF measure at baseline and at 4 months were available.
Results. There were 2728/4550 patients (59.9%) who fulfilled the criteria for ICD implantation. At 4 month, 888 (32.5%) of these patients were no longer eligible for an ICD implant, mainly because of an improvement in EF (635/888,71.5%). The 2-year outcomes in patients with or without the criteria for ICD implantation are shown in the table⇓. There were a total 375 SCDs, 261 (9.6%) in the group with indication for ICD, and 114 (6.3%) in the group without indication for ICD. If an ICD was implanted in all patients with a clinical indication for ICD, at best 261 sudden cardiac deaths (SCD) could have been avoided, whereas the device would have been useless in the remaining 2467. Conversely, 30% (114/375) of the SCD that occurred in the group without an indication for an ICD would not have been prevented.
Conclusion. These findings suggest that the current guidelines for ICD implantation are unsatisfactory and that risk stratification aimed at a better identification of patients at high risk for SCD is necessary to significantly reduce the number of patients to be implanted with an ICD to save one SCD.