Is ICD effective in primary prevention od Sudden Cardiac Death in patients with heart failure of nonischemic etiology?

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In DANISH trial, published in 2016, beneficial effect of implantation of cardioverter-defibrillator on mortality in population of patients with heart failure of nonischemic etiology was not demonstrated. It should be pointed out that up to 58% of patients in both arms received cardiac resynchronization therapy, so there were not two but four arms of the trial: optimal medical therapy, ICD, CRTP, CRTD with respective mortality: 27; 25; 20 and 19% (p=0,08). In the trial 50% relative risk reduction of arrhythmic death was observed and beneficial effect on mortality was demonstrated in population under 59 years treated with ICD. Twenty four patients in non-ICD group were implanted during the trial because of arrhythmia. If composite end point would be defined as total mortality and necessity to implant ICD because of arrhythmia the difference between groups would reach statistical significance (p=0,0181). In metaanalysis of AMIOVIRT, CAT COMPANION, DEFINITE SCD-HeFT and DANISH 24% reduction in total mortality was demonstrated. Even if COMPANION will be removed from the analysis still 20% beneficial effect of ICD will be present. In large analysis of 45 trials on risk factors of arrhythmic events in the population of dilated cardiomyopathy the following had impact on this risk: LVEDD, LVEF, EPS results, presence of nsVT, QRS prolongation, LBBB, results of SAECG, fragmented QRS, QRS-T angle and TWA. DANISH trial, despite its importance, does not justify discontinuing ICD therapy in patients with nonischemic heart failure.