{"id":1333,"date":"2009-11-10T22:50:11","date_gmt":"2009-11-11T03:50:11","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/deciding-who-gets-prophylactic-icds-%e2%80%94-we-need-a-better-way\/"},"modified":"2011-07-19T17:45:31","modified_gmt":"2011-07-19T21:45:31","slug":"deciding-who-gets-prophylactic-icds-%e2%80%94-we-need-a-better-way","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2009\/11\/10\/deciding-who-gets-prophylactic-icds-%e2%80%94-we-need-a-better-way\/","title":{"rendered":"Deciding Who Gets Prophylactic ICDs \u2014 We Need a Better Way"},"content":{"rendered":"

The ACC\/AHA guidelines<\/a> endorse prophylactic ICDs for NYHA Class II\/III patients with an LV ejection fraction \u226435%, but I\u2019m reluctant to recommend this to my patients who are doing really well. Why put them through the hassle and risk? Will they really benefit, especially if I think they\u2019re just as likely to get an inappropriate shock as a life-saving one? A recent paper in Circulation<\/a> has caused me to reconsider my approach.
\nWayne Levy and colleagues used a modified version of the Seattle Heart Failure Model to identify which patients meeting the ACC\/AHA criteria will\u00a0benefit most from prophylactic ICDs versus medication alone. They found that ICDs offered substantial benefit for patients at low risk for overall mortality \u2014 but provided no benefit for those in the highest quintile of risk (i.e., patients with a projected annual mortality rate approaching 20%). This really impressed me, because I\u2019ve been especially reluctant to recommend ICDs to patients who I perceive to have the best prognosis.\u00a0
\nTwo important insights from this work: <\/p>\n

\u00a0We often presume that the greater a patient\u2019s underlying risk, the greater the benefit of a given intervention. But, in the setting of heart failure, where ICDs protect only against arrhythmic death and not against death from pump failure, the competing risk of death from pump failure can swamp the potential benefits of protection from arrhythmic death. Confirming this was the observation that in the highest-risk patients, there was, in fact, a nonsignificant 24% reduction<\/em> in sudden cardiac death, despite no benefit in overall mortality. <\/p>\n

Risk-prediction models can give us a better sense of how individual patients might respond to a given treatment, so that we can tailor therapy to their individualized estimate of therapeutic benefit, as well as their personal goals and preferences. To do this, however, we need to start developing the infrastructure to implement validated, evidence-based risk stratification at the time of medical decision-making.<\/p>\n

Until this additional research is accomplished, how will you apply the insights of Dr. Levy\u2019s study in your practice? Do you think the modified Seattle Heart Failure model is the best way to stratify risk, or are there other mortality estimates that you might use? If so, which ones? How will you routinely incorporate these into your practice?
\n\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"

The ACC\/AHA guidelines endorse prophylactic ICDs for NYHA Class II\/III patients with an LV ejection fraction \u226435%, but I\u2019m reluctant to recommend this to my patients who are doing really well. Why put them through the hassle and risk? Will they really benefit, especially if I think they\u2019re just as likely to get an inappropriate […]<\/p>\n","protected":false},"author":760,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1333","post","type-post","status-publish","format-standard","hentry","category-general"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1333","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/760"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1333"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1333\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1333"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1333"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1333"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}