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Europace Advance Access published online on June 7, 2006
Europace, doi:10.1093/europace/eul052
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© The European Society of Cardiology 2006. All rights reserved
Received October 18, 2005
Accepted March 19, 2006

Article

ICD therapy: ‘the sickest benefit the most...’: what about the less sick?

Karl-Heinz Kuck 1 * and Seah Nisam 2

1 Ak St. Georg Kardiologische Abteilung, Lohmühlenstrasse 5, 20099 Hamburg, Germany
2 Guidant Corporation, Park Lane Culliganlaan 2B, Diegem, Belgium

* To whom correspondence should be addressed.
Karl-Heinz Kuck, E-mail: karl_heinz.kuck{at}ak-stgeorg.lbk-hh.de


  Abstract

Implantable cardioverter defibrillators (ICDs) have been proven to be highly efficacious in protecting very high-risk cardiac patients from sudden cardiac death and hence enhancing their overall survival. Furthermore, several post hoc sub-study analyses seem to indicate that ICD benefit is predominant in the patients with the highest risk, particularly with depressed left ventricular function. This, in turn, has led some clinicians to question the benefit of ICD therapy in relatively healthy, i.e. ‘less sick’, patients. As these interpretations come entirely from the sub-group analyses of the completed ICD prospective studies, it is important to examine more profoundly the study design, length of follow-up, and outcomes of these studies. Such analysis identifies three primary reasons why the conclusion that ‘less sick’ patients benefit less from ICD therapy may be erroneous: (i) the relatively short follow-up time of the studies (ended as soon as ICD therapy benefit became manifest); (ii) high ‘crossover rate’ from control to ICD therapy; and (iii) predominance of study endpoints (deaths) in the ‘sickest’ patients. The results of several studies, including the most recent and largest ICD study--SCD-Heft--and sub-group analyses of ‘healthier’ patient cohorts in several studies, support the benefit of ICDs in this group of patients, provided the follow-up time is sufficiently long.

Keywords: Implantable cardioverter defibrillator; Sudden death; Left ventricular dysfunction; Heart failure.
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