Implantable cardioverter-defibrillator: A Volkswagen or a Rolls Royce: how much will we pay to save a life?

Abstract

A 45-year-old man with end-stage cardiomyopathy died while waiting for a heart transplant after living almost 1 year in a coronary care unit supported by intravenous medications. Around the time of his death, an off-duty police officer in a neighboring town watching a high school football game saw one of the player’s fathers slump forward unconscious. The officer ran to his patrol car, grabbed the automated external defibrillator he had recently been assigned, and defibrillated the father’s ventricular fibrillation. The man immediately regained consciousness and protested being taken to the hospital because he wanted to watch his son finish the game! These extremes provide dramatic bookends to the spectrum of how we spend money to save a life. Some therapies are inexpensive and others are not, and society has to make difficult choices about how to use our limited resources. The implantable cardioverter-defibrillator (ICD) represents one of the most important advances in the past 50 years in the treatment of patients with life-threatening ventricular tachyarrhythmias.1 Five pivotal prospective, randomized, clinical trials have helped define its use. In 3 secondary prevention trials, Antiarrhythmics Versus Implantable Defibrillators (AVID), Canadian Implantable Defibrillator Study (CIDS), and Cardiac Arrest Survival Hamburg (CASH),2 and 2 primary prevention trials, Multicenter Automatic Defibrillator Implantation Trial (MADIT)3 and Multicenter Unsustained Tachycardia Trial (MUSTT),4 the ICD was superior to antiarrhythmic drugs (mostly or exclusively amiodarone) in reducing mortality in patients with life-threatening ventricular tachyarrhythmias. Further analysis of data from the 3 secondary prevention trials established that the ICD did not confer added benefit compared with amiodarone in patients who had ejection fractions (EF) >35%.2 5 Additional examination of data from CIDS6 showed that patients who were in the highest risk quartile enjoyed a 50% relative risk reduction in mortality from the ICD that was …