COMMENTARY
Benefits of the Implantable Cardioverter-Defibrillator
Andrew E. Epstein, MD, FACC*
Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
Manuscript received May 28, 2008;
accepted June 12, 2008.
* Reprint requests and correspondence: Dr. Andrew E. Epstein, Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Tinsley Harrison Tower 321L, 1530 3rd Avenue South, Birmingham, Alabama 35294 (Email: aepstein{at}uab.edu).
The state-of-the-art review by Tung and colleagues provides a thoughtful perspective on balancing the benefits and risks of implantable cardioverter-defibrillator (ICD) therapy addressing the concerns of many caring physicians. In this response: 1) the clinical benefits of ICD therapy are reviewed using the evidence base resulting from controlled clinical trials; 2) untoward effects of ICDs on quality of life are acknowledged, and it is argued that they do not negate the results of studies in which the aggregate show benefit; and 3) cost-effectiveness of ICD therapy is considered. Although clinical trials evaluating ICD therapy have limitations, there are few interventions in which multiple trial settings have consistently over a >10-year period produced a 20% to 30% reduction in total mortality. Research to better identify patients expected to benefit from ICD therapy is ongoing, but at present we have the results of clinical trials that show improved survival in a broad selection of patients with left ventricular dysfunction and either demonstrated or anticipated risk for arrhythmic death. Evidence-based medicine; the rigorous process of guideline writing, review, and approval; and the ethical consideration of offering proven life-prolonging therapies to all patients provide a compelling rationale for clinicians to carefully consider guidelines in their clinical decision making. Updates in the new Device-Based Therapy Guidelines for the implantation of ICDs and pacemakers advance these goals.
Key Words: implantable cardioverter-defibrillator • evidence-based medicine • sudden death • guidelines • clinical trial
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Abbreviations and Acronyms
| | CRT = cardiac resynchronization therapy | | ICD = implantable cardioverter-defibrillator | | LVEF = left ventricular ejection fraction | | PVC = premature ventricular contraction | | SCD = sudden cardiac death |
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