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Impact of implantable-cardioverter-defibrillator trials on clinical management of patients with heart failure

Nature Clinical Practice Cardiovascular Medicine volume 3, pages 86–93 (2006)Cite this article

Abstract

Heart failure is a deadly disease. Every year, tens of thousands of patients die from this condition, many of them suddenly. Efforts aimed at reducing mortality centered initially on antagonizing the neurohormonal system, which is maladaptively upregulated in response to myocardial failure. Antagonists of the renin–angiotensin–aldosterone and adrenergic nervous systems have reduced the rates of cardiovascular mortality and sudden cardiac death. Antiarrhythmic drug therapy has not fared as well. Consequently, efforts to reduce the risk of sudden death have focused on the use of implantable cardioverter-defibrillators (ICDs). How best to identify patients who will benefit from this invasive and expensive therapy has yet to be clearly determined. In this review, we discuss the effectiveness of ICDs in primary and secondary prevention of sudden death in heart failure patients, and examine the impact that the use of ICDs has had on clinical decision making.

Key Points

  • Antiarrhythmic drugs have failed to reduce the risk of sudden death in patients with heart failure, and implantable cardioverter-defibrillators are becoming the therapy of choice

  • Less than 5% of patients survive sudden cardiac death, but in survivors implantable cardioverter-defibrillators can significantly reduce subsequent events

  • Implantable cardioverter-defibrillators are useful for primary prevention of sudden death in patients with ischemic heart disease, but in those with nonischemic disease the benefits are less clear

  • Cardiac resynchronization therapy can improve outcomes when used with biventricular pacemaker devices

  • Identification of patients at the highest risk needs to be improved, to avoid unnecessary treatment and risk of complications in low-risk patients

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Figure 1: Suggested schema for the identification of patients suitable for device therapy.

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Author information

Authors and Affiliations

  1. Fellow in Electrophysiology at the Brigham and Women's Hospital, Boston, MA, USA

    Robert D Winslow

  2. Advanced Heart Failure and Transplant program,

    Sean Pinney & Valentin Fuster

  3. Zena and Michael A Weiner Cardiovascular Institute and the Marie-Josée and Henry R Kravis Center for Cardiovascular Health, at the Mount Sinai Medical Center, New York, NY, USA

    Sean Pinney & Valentin Fuster

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  1. Robert D Winslow
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Correspondence to Valentin Fuster.

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Winslow, R., Pinney, S. & Fuster, V. Impact of implantable-cardioverter-defibrillator trials on clinical management of patients with heart failure. Nat Rev Cardiol 3, 86–93 (2006). https://doi.org/10.1038/ncpcardio0450

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