Identifying the patient who FADES away prior to appropriate ICD intervention

Despite important progress, sudden cardiac death (SCD) continues to represent an important clinical challenge for contemporary cardiology. Randomised controlled trials performed in high risk patients, such as patients with ischaemic heart disease and left ventricular dysfunction, showed that an approach based on antiarrhythmic drugs is not only useless, but sometimes even potentially harmful.1 Conversely, implantable cardioverter defibrillators (ICDs) have gained a specific role not only in patients with a previous ventricular tachyarrhythmia or cardiac arrest (secondary preventions of SCD) but also in the broader population of high-risk patients with ischaemic heart disease and left ventricular dysfunction, in whom use of ICDs for primary prevention of SCD may reduce overall mortality by 23%–54%.1 The high upfront cost of ICDs, particularly when implementing cardiac resynchronisation therapy (CRT-D), has prompted both the search to improve patient targeting and the development of appropriate economic evaluations on the cost-effectiveness of device therapy.2 3 According to the first strategy, there is growing interest in outcome research, including studies aimed at characterising which patients implanted with an ICD in the ‘real world’ die without or prior to appropriate ICD therapy. In this issue of Heart , van Rees et al from Leiden University in the Netherlands report on the results of a single-center study focused on the outcome of patients with ischaemic heart disease implanted with a cardioverter-defibrillator (ICD) for primary prevention of SCD, according to consensus guidelines ( see page 872 ).4 A retrospective cohort of more than 900 pts, with a mean age of 64 years and NYHA class I-II was analysed. Half of the patients received a biventricular ICD, that is a CRTD device, while the remaining patients received a dual-chamber ICD and only a minority a simple single-chamber ICD. …