Reassessing the need for ICDs in heart failure
New research has revealed that medication is so effective in reducing the risk of sudden death in patients with heart failure with reduced ejection fraction that the overall benefit of implantable cardioverter-defibrillators (ICDs) is uncertain. The research analysed individual patient data from 12 clinical trials conducted between 1995 and 2014 including 40,000 patients.
The study found that rates of sudden death had declined by 44% in the 19 years assessed, and that this decline paralleled the increased use of medications including beta-blockers, ACE inhibitors and mineralocorticoid receptor antagonists.
Professor John McMurray, Professor of Cardiology at the University of Glasgow and senior author of the study, said: “The low risk of sudden death in patients treated with a combination of effective medications reflects an extremely important improvement in outcomes for patients with heart failure.”
Current guidance suggests that heart failure patients should be given three months on medication before assessing whether it is necessary to fit an ICD, although some doctors do not wait this long. However, the results of this paper suggest that doctors might be able to wait longer, as improvements in heart function may still occur up to six and even 12 months after the start of medical treatment and the new data from this study show that the rate of sudden death remains low over this period. The researchers add that while medication may be the right treatment on the whole, there will still be some high-risk patients for whom an ICD device would be the best option.
Professor McMurray said: “Our study suggests that new efforts are needed to better identify the high-risk subgroup of patients who would benefit most from ICD implantation.”
This study suggests that appropriate patients with heart failure may benefit from longer periods of treatment with heart failure medication before requiring an ICD. Heart failure medications have been highly successful in reducing the incidence of sudden death.
Shen L, Jhund PS, Petrie MC et al. Declining risk of sudden death in heart failure. New Eng J Med 2017;377(1):41-51. www.ncbi.nlm.nih.gov/pubmed/28679089]