What are indications for implantable cardioverter-defibrillators (ICD) therapy in primary prophylaxis?

Updated: Feb 13, 2017
  • Author: Daniel M Beyerbach, MD, PhD; Chief Editor: Jeffrey N Rottman, MD  more...
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Answer

Answer

Indications for an ICD implant as primary prophylaxis against sudden cardiac death are listed in the Table 1, below. The indications are listed as class I or class IIa, as classified by the 2008 American College of Cardiology and American Heart Association (ACC/AHA) guidelines. Class I means that the treatment is useful, that its benefit greatly outweighs the risk, and that it should be administered.

Class IIa means that the benefit outweighs the risk and it is reasonable to administer the treatment. Class IIb means that the benefit probably outweighs the risk and that the treatment may be considered. Class III means that the risk outweighs the benefit, and the treatment should not be performed. Only Class I and Class IIa indications are included in the table. For a complete list, the reader is referred to the 2008 ACC/AHA guidelines. [1]

The greatest predictors of risk for sudden cardiac death include left ventricular systolic function and heart failure symptoms. The vast majority of investigational studies have quantified left ventricular systolic function using the measure of left ventricular ejection fraction (LVEF). The most widely used form of heart failure symptom classification is the New York Heart Association (NYHA) functional class classification system, which classifies mild to no symptoms as Class I, and the most severe symptoms as Class IV.

Table 1. Indications for ICD Implant (Open Table in a new window)

Indication

Classification

Supporting Studies

Structural heart disease, sustained VT

Class I

AVID, CASH, CIDS

Syncope of undetermined origin, inducible VT or VF at EPS

Class I

CIDS

LVEF ≤35% due to prior MI, at least 40 days post-MI, NYHA Class II or III

Class I

SCD-HeFT

LVEF ≤35%, NYHA Class II or III

Class I

SCD-HeFT

LVEF ≤30% due to prior MI, at least 40 days post-MI

Class I

MADIT II

LVEF≤40% due to prior MI, inducible VT or VF at EPS

Class I

MADIT, MUSTT

Unexplained syncope, significant LV dysfunction, nonischemic CM

Class IIa

Expert opinion

Sustained VT, normal or near-normal ventricular function

Class IIa

Expert opinion

Hypertrophic cardiomyopathy (CM) with 1 or more major risk factors

Class IIa

Expert opinion

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) with 1 or more risk factors for sudden cardiac death (SCD)

Class IIa

Expert opinion

Long QT syndrome, syncope or VT while receiving beta blockers

Class IIa

Zareba et al, [37]  Viskin et al, [38]  Goel et al, [39]  Monnig et al, [40]  Goldenberg et al, [41]  Hobbs et al [42]

Nonhospitalized patients awaiting heart transplant

Class IIa

Expert opinion

Brugada syndrome, syncope

Class IIa

Expert opinion

Brugada syndrome, VT

Class IIa

Expert opinion

Catecholaminergic polymorphic VT, syncope or VT while receiving beta blockers

Class IIa

Expert opinion

Cardiac sarcoidosis, giant cell myocarditis, or Chagas disease

Class IIa

Expert opinion

CM = cardiomyopathy; EPS = electrophysiologic studies; ICD = implantable cardioverter-defibrillator; LVEF = left ventricular ejection fraction; MI = myocardial infarction; NYHA = New York Heart Association; VF = ventricular fibrillation; VT = ventricular tachycardia.


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