Best Clinical Practice: Art, Science, or Both?:  Comment on “Implantable Cardiac Device Procedures in Older Patients”

Since its inception in the 1980s, the ICD has evolved from a rarely used “last resort” procedure to an essential and commonly used treatment for patients at risk for sudden cardiac death. Approximately 400 000 ICDs were implanted in the United States during the last 3 years, with a current implantation rate of 10 000 to 12 500 ICDs per month.¹

Several landmark studies have demonstrated that ICDs improve survival in selected patient populations. In the MADIT-II,² ICD implantation was associated with a significant 30% reduction in mortality among patients with coronary artery disease and reduced ejection fraction (<0.30). Similarly, in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT),³ ICD implantation was associated with a significant 20% to 25% reduction in mortality among patients with class II or III heart failure and ejection fraction less than 0.35 regardless of origin. As a result, in 2005 the Centers for Medicare and Medicaid Services decided to cover ICD implantation in patients who fit these criteria but mandated creation of a national ICD Registry because the mean age in both trials (65 years in the MADIT-II and 60 years in the SCD-HeFT) was younger than the Medicare population.