Shouldn’t Everyone Have an Implantable Cardioverter-Defibrillator?

Abstract

Benjamin Franklin was the first to suggest that electricity be used to revive a person from death, although the first actual case was reported in 1774 when a 3-year-old trauma victim was revived with electric shocks to her chest delivered from an early capacitor called a Leyden jar.1 More than 200 years later, the concept of terminating life-threatening arrhythmias with electric therapy has evolved greatly owing in part to the seminal work of Mirowski et al2 and the development of the implantable cardioverter-defibrillator (ICD).2 Although few would dispute the efficacy with which these devices recognize and terminate life-threatening ventricular arrhythmias, questions persist. In this issue of Circulation , Packer and colleagues3 provide an important substudy of the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) and in doing so allow further insight into the both the marvels and limitations of ICD therapy. Article see p 2170 SCD-HeFT stands as the largest of the groundbreaking clinical studies that have firmly established the place of ICDs in the armamentarium of heart failure treatment. The trial randomized 2521 subjects with an ejection fraction ≤35% caused by either ischemic or nonischemic cardiomyopathy and New York Heart Association (NYHA) class II or III heart failure to receive conventional therapy alone, conventional therapy plus amiodarone, or conventional therapy with a shock-only single-chamber ICD. The study demonstrated a 23% reduction in all-cause mortality in patients randomized to receive an ICD with no benefit from amiodarone compared with conventional therapy.4 What was not provided in the initial report is how the ICD reduced mortality, but Packer and colleagues have …