Disrupting the Approach to Sudden Cardiac Death
From Vulnerable Ejection Fraction to Vulnerable Patient
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Our current approach to primary prevention of sudden cardiac death has reached a point where we are experiencing diminishing returns on 2 decades of investment. What is the evidence for this disturbing phenomenon? Contemporary real-world data indicate that no more than 3% to 5% of primary prevention implantable cardioverter-defibrillators (ICDs), implanted on the basis of left ventricular ejection fraction (LVEF) <30% to 35%, deliver life-saving therapies on an annual basis.1 Eventually, given the significantly larger subgroup that does not benefit from the device, the cost of providing this preventive intervention is not going to be sustainable. Why are we in this predicament?
The landmark primary prevention ICD trials of 2 decades ago delivered LVEF <30% to 35% as the major indication for implanting the prophylactic ICD. Over time, largely because of improved hypertension, heart failure, and ischemic heart disease management, awareness, and education,2 the utility of this criterion has dwindled, yet our approach remains the same. Furthermore, the recognition that the vast majority (≥70%) of patients that experience sudden cardiac death (SCD) have LVEF >35%3 is clamoring for new ways of identifying patients most likely to benefit, but we do not have these yet. I would submit that we have reached an impasse in the field of SCD primary prevention, and it is past time …