Debate: Do all patients with heart failure require implantable defibrillators to prevent sudden death?

Abstract

This issue of Current Controlled Trials in Cardiovascular Medicine contains two diametrically opposite views of whether all patients with heart failure require an implanted cardioverter-defibrillator (ICD) to prevent sudden death. Hsia et al [1] propose targeting the general population with mild to moderate heart failure with 'empirical' ICD therapy. Goldstein [2] on the other hand argues that this would represent a huge logistic and economic expense and that it would therefore be necessary to firstly identify the heart failure subpopulation that could benefit from this. Before analysing the essence of this debate, let me first point out areas of agreement. Both sets of authors agree that angiotensin-converting-enzyme inhibitors (ACEIs) have a major impact on the prognosis of heart failure. It is the achievement of randomised clinical trials (RCTs) athat there is agreement on this point. Until the results of the CONSENSUS trial [3] were published, there was disagreement on the role of ACEIs, particularly in severe heart failure, because of their potential to reduce renal function. In fact, the steering committee of CONSENSUS was stunned when it was told by the data monitoring committee to stop the trial because of the large mortality reduction conferred by enalapril. They thought that the trial had to be stopped because of an excess mortality in the enalapril group. Both sets of authors also agree on the beneficial effect of beta-blockers. Again this is the achievement of research. Until recently, prescribing a beta-blocker for heart failure was considered malpractice and a reason for firing the junior doctor who did so.