Key result
Contemporary HF therapy fails to reduce appropriate ICD therapies compared to historical management.
Why the study?
ICD benefit for primary prevention in HFrEF patients is uncertain in the contemporary treatment era with widespread ARNI and SGLT2i use, as landmark trials predate these therapies.
Does contemporary guideline-directed medical therapy era (with widespread ARNI/SGLT2i adoption) reduce the incidence of appropriate ICD therapies compared to a historical era in patients with HFrEF and primary prevention ICDs?
Cohort (n=289)
No
Does contemporary guideline-directed medical therapy era (with widespread ARNI/SGLT2i adoption) reduce the incidence of appropriate ICD therapies compared to a historical era in patients with HFrEF and primary prevention ICDs?
Answers are grounded in this paper and cite their sources.
In patients with HFrEF undergoing primary prevention ICD implantation, there was no significant difference in rates of appropriate ICD therapy between the contemporary era with widespread ARNI and SGLT2i use and the historical era, suggesting that residual arrhythmic risk persists despite advances in guideline-directed medical therapy.
Background In heart failure with reduced ejection fraction (HFrEF), a substantial proportion of deaths are arrhythmic. Implantable cardioverter‐defibrillators (ICDs) are recommended for primary prevention in patients with left ventricular ejection fraction (LVEF) ≤ 35% despite guideline‐directed medical therapy (GDMT), but landmark trials predate widespread use of angiotensin receptor–neprilysin inhibitors (ARNI) and sodium–glucose cotransporter 2 inhibitors (SGLT2i), raising uncertainty about arrhythmic risk in the contemporary treatment era. Methods We retrospectively studied consecutive HFrEF patients undergoing primary‐prevention ICD implantation at a single center (2015–2022), categorized into historical‐era and contemporary‐era cohorts by ARNI/SGLT2i adoption. Propensity‐score matching balanced baseline characteristics. The primary endpoint was time to first appropriate ICD therapy (antitachycardia pacing or shock). Results Of 289 patients (mean age 62 ± 11 years, 82% male), 234 (117 per group) remained after matching. Mean follow‐up was 51 months. Appropriate ICD therapy incidence did not differ significantly between contemporary‐era and historical‐era cohorts (hazard ratio [HR] 1.52, 95% CI 0.84–2.72; p = 0.165). Competing‐risk‐adjusted cumulative incidence was numerically higher in the contemporary‐era cohort at a pre‐specified 36‐months horizon, consistent with a sensitivity analysis using an expanded propensity‐score model (HR 1.55, 95% CI 0.82–2.94). Conclusion ICD therapy rates were not significantly different between the contemporary‐era and historical‐era cohorts, a finding robust to sensitivity and competing‐risk analyses. These results should be interpreted cautiously, as the study may be underpowered to detect modest differences, and clinically relevant effects cannot be excluded.
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Neves et al. (2026) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=289). Contemporary-era GDMT adoption (ARNI/SGLT2i era) vs. Historical-era cohort (before widespread ARNI/SGLT2i use) was evaluated on Time to first appropriate ICD therapy (antitachycardia pacing or shock) (HR 1.52, 95% CI 0.84-2.72, p=0.165). Contemporary-era heart failure management, characterized by ARNI and SGLT2i adoption, did not significantly alter the incidence of appropriate ICD therapies compared to a historical-era cohort (HR 1.52).
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