The 2018 Australian guidelines recommendations require further clarification to ensure eligible patients will receive appropriate ICD therapy
The implantable cardioverter defibrillator (ICD) has been shown to be a cost‐effective option for primary prevention of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). However, in the recently published 2018 guidelines for the prevention, detection and management of heart failure in Australia, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Heart Failure Guidelines Working Group downgraded the recommendation for primary prevention ICD to decrease mortality in patients with HFrEF and left ventricular ejection fraction (LVEF) 35% or below associated with non‐ischaemic cardiomyopathy (NICM).1,2 In particular, the level of recommendation and quality of evidence for primary prevention ICD was deemed weak and low for NICM versus strong and moderate for ischaemic cardiomyopathy, respectively. The document cited the lack of single randomised controlled trials demonstrating mortality benefits with primary prevention ICD in patients with NICM. It also highlighted recent prospective randomised controlled data of 1116 patients with HFrEF and LVEF 35% or below associated with non‐ischaemic causes from the DANISH trial — a Danish study to assess the efficacy of ICD in patients with non‐ischaemic systolic heart failure on mortality — whereby primary prevention ICD did not reduce mortality compared with usual clinical care over a median follow‐up duration of 67.6 months (interquartile range, 49–85 months).3
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- 1. Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of heart failure 2018. Med J Aust 2018; 209: 363–369. https://www.mja.com.au/journal/2018/209/8/national-heart-foundation-australia-and-cardiac-society-australia-and-new-0
- 2. Atherton JJ, Sindone A, De Pasquale CG, et al; NHFA CSANZ Heart Failure Guidelines Working Group. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: guidelines for the prevention, detection, and management of heart failure in Australia 2018. Heart Lung Circ 2018; 27: 1123–1208.
- 3. Kober L, Thune JJ, Nielsen JC, et al. Defibrillator implantation in patients with nonischemic systolic heart failure. N Engl J Med 2016; 375: 1221–1230.
- 4. Bennett M, Parkash R, Nery P, et al. Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 implantable cardioverter‐defibrillator guidelines. Can J Cardiol 2017; 33: 174–188.
- 5. Al‐Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2018; 15: e73–e189.
- 6. Haugaa KH, Tilz R, Boveda S, et al. Implantable cardioverter defibrillator use for primary prevention in ischaemic and non‐ischaemic heart disease‐indications in the post‐DANISH trial era: results of the European Heart Rhythm Association survey. Europace 2017; 19: 660–664.
- 7. Al‐Khatib SM, Fonarow GC, Joglar JA, et al. Primary prevention implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy: a meta‐analysis. JAMA Cardiol 2017; 2: 685–688.
- 8. Golwala H, Bajaj NS, Arora G, Arora P. Implantable cardioverter‐defibrillator for nonischemic cardiomyopathy: an updated meta‐analysis. Circulation 2017; 135: 201–203.
- 9. Luni FK, Singh H, Khan AR, et al. Mortality effect of ICD in primary prevention of nonischemic cardiomyopathy: a meta‐analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2017; 28: 538–543.
- 10. Shun‐Shin MJ, Zheng SL, Cole GD, et al. Implantable cardioverter defibrillators for primary prevention of death in left ventricular dysfunction with and without ischaemic heart disease: a meta‐analysis of 8567 patients in the 11 trials. Eur Heart J 2017; 38: 1738–1746.
- 11. Bristow MR, Saxon LA, Boehmer J, et al; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac‐resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350: 2140–2150.
- 12. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long‐term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342: 1077–1084.
- 13. Elming MB, Nielsen JC, Haarbo J, et al. Age and outcomes of primary prevention implantable cardioverter‐defibrillators in patients with nonischemic systolic heart failure. Circulation 2017; 136: 1772–1780.
- 14. Thavapalachandran S, Leong DP, Stiles MK, et al. Evidence‐based management of heart failure in clinical practice: a review of device‐based therapy use. Intern Med J 2009; 39: 669–675.
- 15. Munawar DA, Mahajan R, Linz D, et al. Predicted longevity of contemporary cardiac implantable electronic devices: a call for industry‐wide “standardized” reporting. Heart Rhythm 2018; 15: 1756–1763.
- 16. Pathak RK, Sanders P, Deo R. Primary prevention implantable cardioverter‐defibrillator and opportunities for sudden cardiac death risk assessment in non‐ischaemic cardiomyopathy. Eur Heart J 2018; 39: 2859–2866.
Dennis Lau is supported by the Robert J Craig Lectureship from the University of Adelaide. Jonathan Kalman and Prashanthan Sanders are supported by Practitioner Fellowships from the National Health and Medical Research Council. Prashanthan Sanders is supported by the National Heart Foundation of Australia.
The University of Adelaide reports receiving on behalf of Dennis Lau lecture and/or consulting fees from Abbott, Bayer, Biotronik and Pfizer. Prashanthan Sanders reports having served on the advisory board of Biosense‐Webster, Medtronic, Abbott, Boston Scientific and CathRx. The University of Adelaide reports receiving on behalf of Prashanthan Sanders lecture and/or consulting fees from Biosense‐Webster, Medtronic, Abbott, and Boston Scientific. The University of Adelaide reports receiving on behalf of Prashanthan Sanders research funding from Medtronic, Abbott, Boston Scientific, Biotronik and Liva Nova.