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. 2022 Jul;24(7):1212-1222.
doi: 10.1002/ejhf.2530. Epub 2022 May 22.

Predictors of primary prevention implantable cardioverter-defibrillator use in heart failure with reduced ejection fraction: impact of the predicted risk of sudden cardiac death and all-cause mortality

Benedikt Schrage  1   2 , Lars H Lund  1   3 , Lina Benson  1 , Ulf Dahlström  4 , Ramin Shadman  5 , Cecilia Linde  1   3 , Frieder Braunschweig  1   3 , Wayne C Levy  6 , Gianluigi Savarese  1   3
Affiliations

Predictors of primary prevention implantable cardioverter-defibrillator use in heart failure with reduced ejection fraction: impact of the predicted risk of sudden cardiac death and all-cause mortality

Benedikt Schrage et al. Eur J Heart Fail. 2022 Jul.

Abstract

Aims: Use of implantable cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death (SCD) in heart failure with reduced ejection fraction (HFrEF) is limited. We aimed to investigate barriers to ICD use in HFrEF while considering the predicted risk of mortality and SCD.

Method and results: Patients from the SwedeHF registered in 2011-2018 and with an indication for primary prevention ICD were analysed. The Seattle Proportional Risk and Seattle Heart Failure Models were used to predict the proportional SCD and all-cause mortality risk, respectively. A multivariable logistic regression model was fitted to identify independent predictors of ICD use/non-use; Cox regression models to evaluate the interaction between predicted SCD/mortality risk and ICD use for mortality. Of 13 475 patients, only 15.5% had an ICD. Those with higher predicted proportional SCD risk (>45%) had an ∼80% higher likelihood to have an ICD. Other predictors of non-use were follow-up in primary versus specialty care, higher comorbidity burden and lower socioeconomic status. ICD use was associated with lower mortality only in patients with higher predicted SCD and lower mortality risk (34% and 37% relative risk reduction for 3-year all-cause and cardiovascular mortality, respectively). In this subgroup of patients, underuse of ICD was 81.8%.

Conclusion: In a contemporary registry, only 15.5% of patients with an indication for primary prevention ICD received the device. While a high predicted proportional SCD risk was appropriately linked to ICD use, the lack of specialized follow-up, higher comorbidity burden, and lower socioeconomic status were major unjustified impediments to implementation. Our findings suggest areas for improving ICD use for primary prevention of SCD in clinical practice.

Keywords: Guideline recommendation; Heart failure with reduced ejection fraction; Implantable cardioverter-defibrillator; Implementation; Primary prevention; Underuse.

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Figures

Figure 1
Figure 1
Independent predictors of implantable cardioverter‐defibrillator (ICD) use. The underlying logistic regression model was adjusted for all variables shown in the forest plot. Additionally, it was also adjusted for cardiac resynchronization therapy use, which was strongly associated with ICD use (odds ratio 20.09, 95% confidence interval 17.64–22.87), but which was omitted from the forest plot since its association was out of proportion as compared to the other variables. COPD, chronic obstructive pulmonary disease; HF, heart failure; NTproBNP, N‐terminal pro‐B‐type natriuretic peptide; SCD, sudden cardiac death; TIA, transient ischaemic attack.
Figure 2
Figure 2
Implantable cardioverter‐defibrillator (ICD) use in the study cohort per proportional risk of sudden cardiac death (SCD) and all‐cause mortality risk.
Figure 3
Figure 3
Association between implantable cardioverter‐defibrillator (ICD) use and 3‐year all‐cause and cardiovascular (CV) mortality across different strata of predicted risk of sudden cardiac death (SCD) and all‐cause mortality. The underlying Cox regression model was adjusted for all variables shown in Figure  1 . CI, confidence interval; HR, hazard ratio.
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References

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