ICD in Heart Failure: Think Outside the Box

Dr. László Littmann received his MD degree from the Semmelweis University Medical School with the Honor of “Sub Auspiciis Rei Publicae Popularis” in 1970, and his PhD degree from the Hungarian Academy of Sciences in 1983. In collaboration with Dr. József Tenczer at the 3rd Department of Medicine, Semmelweis University Medical School, Dr. Littmann was one of the cofounders of clinical cardiac electrophysiology in Hungary. He has been living in the United States since 1987. Dr. Littmann is currently Chief of Cardiology at the Department of Internal Medicine, Carolinas Medical Center in Charlotte, North Carolina, Medical Director of its Heart Failure Program, and since 2000, Professor of Medicine at the University of North Carolina at Chapel Hill. His main clinicaland research interests include electrocardiology, clinical cardiac electrophysiology, arrhythmias, and heart failure. Dr. Littmann received numerous research and teaching awards. He is ad hoc reviewer of all major cardiology journals.

Abstract

Even with optimal medical management, patients with ischemic or nonischemic dilated cardiomyopathy are at risk of sudden cardiac death. Several studies have shown that implantation of a prophylactic cardioverter-defibrillator (ICD) reduces mortality in patients with a left ventricular ejection fraction (EF) of ≤ 35%. The degree of benefit, however, varies among different patient groups. There is minimal or no benefit in persons with advanced renal failure, advanced heart failure, in patients with atrial fibrillation, in those with an EF> 30%, and in the very elderly. Those individuals appear to be the best candidates for prophylactic ICD who, despite optimal medical therapy, continue to have a low EF but good functional performance status without significant renal failure or other comorbidconditions. Patients with ischemic cardiomyopathy and complex ventricular arrhythmias are also more likely to benefit. Obviously there is no benefit from the ICD unless it fires ona life-threatening ventricular arrhythmia but paradoxically those patients who do receive potentially life-saving ICD discharges frequently have a markedly reduced post-shock survival.Understanding these odds, with the help of their physicians, patients need to make personal choices about the desirability of an ICD.