Europace Advance Access published online on May 7, 2008
Europace, doi:10.1093/europace/eun114
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Is there unmet need for implantable cardioverter defibrillators? Findings from a post-mortem series of sudden cardiac death
1 Wessex Institute for Health Research and Development, Southampton University Hospitals, Southampton SO16 7PX, UK; 2 Public Health Medicine and Medical Statistics, Southampton University Hospitals, Tremona Road, Southampton SO16 6YD, UK; 3 Department of Pathology, Southampton University Hospitals, Tremona Road, Southampton SO16 6YD, UK; 4 Wessex Cardiothoracic Centre, Southampton University Hospitals, Tremona Road, Southampton SO16 6YD, UK
Aims: To establish whether sudden cardiac death (SCD) victims could have been identified prior to their event and considered for an implantable cardioverter defibrillators (ICDs).
Methods and results: Consecutive post-mortem cases of adult SCDs presumed to be caused by a ventricular arrhythmia over 12 months (2002–03) from a defined catchment population, Southampton, UK (n = 443 824 adults aged 
16 years). Pathological data were extracted from the post-mortem reports. Hospital and general practice (GP) notes provided data on previous symptoms, investigations, and cardiac disease history. Two electrophysiologists judged the appropriateness of each case for an ICD against National Guidance. Two hundred and fifteen cases met the inclusion criteria and lived within the catchment area. Agreement between experts on appropriateness for an ICD in those aged <80 years was good (kappa score of 0.64). Only one case (<1%) was considered appropriate for an ICD without requirement for further investigation. Forty-nine per cent of cases were considered to have required further cardiac investigations to determine appropriateness; these were mainly heart failure patients who had suffered a myocardial infarction (MI). Forty per cent of cases had no previous clinical evidence of confirmed or suspected heart disease. However, pathological data showed that 51% of cases had suffered a previous MI.
Conclusion: Two-fifths of SCD victims had no recorded health service contact that would indicate increased risk of SCD within their lifetime. A large number of patients suffered previous cardiac events or symptoms suggestive of increased SCD risk but were not referred for further investigations. There is a need for better care pathways for patients post-MI to identify those requiring an ICD. The impact on the ICD rate of undertaking these extra investigations is uncertain.
Key Words: Sudden cardiac death, Implantable cardioverter defibrillator, Case series, Post-mortem, Appropriateness
* Corresponding author. Tel: +44 23 80 597587; fax: +44 23 80 595639.E-mail address: dla1{at}soton.ac.uk
Manuscript submitted 28 March 2007. Accepted after revision 3 February 2008.