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Review
. 2025 Jan;13(1):1-13.
doi: 10.1016/j.jchf.2024.09.014. Epub 2024 Dec 4.

Revisiting ICD Therapy for Primary Prevention in Patients With Heart Failure and Reduced Ejection Fraction

Amin Yehya  1 , Jose Lopez  2 , Andrew J Sauer  3 , Jonathan D Davis  4 , Nasrien E Ibrahim  5 , Roderick Tung  6 , Biykem Bozkurt  7 , Gregg C Fonarow  8 , Sana M Al-Khatib  9
Affiliations
Review

Revisiting ICD Therapy for Primary Prevention in Patients With Heart Failure and Reduced Ejection Fraction

Amin Yehya et al. JACC Heart Fail. 2025 Jan.

Abstract

Implantable cardioverter-defibrillators (ICDs) are recommended to reduce the risk of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). The landmark studies leading to the current guideline recommendations preceded the 4 pillars of guideline-directed medical therapies (GDMTs). Therefore, some have questioned the role of ICDs for primary prevention in current clinical practice. In this paper, the authors provide an overview of the current ICD recommendations, including the instrumental clinical trials, the risk of SCD as observed in clinical trials vs real-world scenarios, disparities in ICD use among different patient populations, the impact of contemporary GDMT on outcomes, and ongoing and future trials and methodologies to help identify patients who are at an increased risk of SCD and who may benefit from an ICD. The authors also propose a pragmatic guidance for clinicians when they engage in the shared decision-making discussions for primary ICD implantation.

Keywords: GDMT; ICD; clinical trials; heart failure; heart failure with reduced ejection fraction; sudden cardiac death.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Yehya has received speaking honoraria and consulting fees from Bayer, Merck, Novo Nordisk, AstraZeneca, and scPharmaceuticals. Dr Sauer has received research funding and consulting or speaking honoraria from Amgen, Abbott, Bayer, Boston Scientific, CSL Vifor, AstraZeneca, Impulse Dynamics, Fire1, uLink, Story Health, General Prognostics, Acorai, Edwards Lifesciences, Rivus, Pfizer, 35Pharma, and Regeneron; and owns stock in ISHI, a privately held digital health company. Dr Bozkurt has received consulting fees from Abbott, Abiomed, American Regent, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cardurion, Cytokinetics, Daiichi Sankyo, Johnson and Johnson, Lantheus, Liva Nova, Merck, Regeneron, Renovacor, Respicardia/Zoll, Roche, Sanofi-Aventis, and Vifor. Dr Fonarow has received consulting fees from Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly, Johnson and Johnson, Medtronic, Merck, Novartis, and Pfizer. Nasrien Ibrahim has received consulting fees from Applied Therapeutics and Cytokinetics. Dr Tung has received speaking honoraria and consulting fees from Medtronic, Abbott, Biotronik, Boston Scientific. All other authors have no relationships relevant to the contents of this paper to disclose.

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