Abstract
Résumé
Heart & Stroke Foundation. Statistics. Available at: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483991/k.34A8/Statistics.htm. Accessed September 1, 2015.
- Ackerman M.J.
- Priori S.G.
- Willems S.
- et al.
- Priori S.G.
- Blomstrom-Lundqvist C.
- Mazzanti A.
- et al.
Patient Selection
Risk assessment of SCD
- Priori S.G.
- Blomstrom-Lundqvist C.
- Mazzanti A.
- et al.
Primary prevention of SCD due to ventricular arrhythmias

Ischemic cardiomyopathy
Nonischemic cardiomyopathy
- Zipes D.P.
- Camm A.J.
- Borggrefe M.
- et al.
- Zipes D.P.
- Camm A.J.
- Borggrefe M.
- et al.
- 1.We recommend that patients with persistent left ventricular dysfunction due to either ischemic or NICM and ejection fraction ≤ 30% receive an ICD, when persistent refers to at least 3 months of OMT in all patients and, in patients with ischemic heart disease, at least 3 months after revascularization and at least 40 days after an MI (Strong Recommendation; High-Quality Evidence).
- 2.We suggest an ICD be considered for patients with persistent left ventricular dysfunction due to either ischemic or NICM and ejection fraction 31%-35% when persistent refers to at least 3 months of OMT in all patients and, in patients with ischemic heart disease, at least 3 months after revascularization and at least 40 days after an MI (Weak Recommendation; Moderate-Quality Evidence).
- 3.We recommend that patients likely to have left ventricular dysfunction 3 months after revascularization for MI or 40 days after MI without revascularization or 3 months following OMT in NICM undergo an assessment of ejection fraction at those time points (Strong Recommendation; Low-Quality Evidence).
- 4.We suggest that an ICD be considered in patients with an acute indication for cardiac pacing within 3 months after revascularization or 40 days of MI and before achieving OMT when there is a high probability that the ejection fraction will remain < 35% (Weak Recommendation; Low-Quality Evidence). (OMT refers to evidenced-based heart failure therapies at their maximally tolerated doses.)
Prediction of the degree of benefit from ICD implantation
Age
Sex differences in ICD therapy and complication rates
- Santini M.
- Russo M.
- Botto G.
- et al.
- Santini M.
- Russo M.
- Botto G.
- et al.
Comorbidity
Use of risk scores to assist with decision-making
Components of Charlson Comorbidity Index: myocardial infarction, congestive heart failure, peripheral vascular disease, dementia, chronic pulmonary disease, connective tissue disease, peptic ulcer disease, liver disease, diabetes, hemiplegia, renal disease, leukemia/lymphoma, metastatic tumour |
Age |
Atrial fibrillation |
New York Heart Association class |
Serum sodium |
Heart Rate Variability |
Frailty
Value | Description | Details |
---|---|---|
1 | Very fit | Robust, active energetic, well-motivated, and fit. Commonly exercise regularly |
2 | Well | Without active disease but less fit than category 1 |
3 | Well with treated comorbid disease | Disease symptoms are well controlled compared with those in category 4 |
4 | Apparently vulnerable | Although not frankly dependent, commonly complain of being slowed or have disease symptoms |
5 | Mildly frail | Limited dependence on others for instrumental activities of daily living |
6 | Moderately frail | Help is needed with activities and instrumental activities of daily living |
7 | Severely frail | Completely dependent, or terminally ill |
How should we use risk scores?
- 5.We recommend that an ICD not be offered to patients in whom comorbidities make it unlikely that an ICD will substantially increase a patient's life expectancy (Strong Recommendation; Moderate-Quality Evidence).
- 6.We recommend that an ICD be replaced by a pacing system, removed, or abandoned at the time of ICD generator end of life/service in patients with life-threatening comorbidities, at the request of the patient, or when an ICD is unlikely to increase life expectancy (Strong Recommendation; Low-Quality Evidence).
Secondary prevention
- Connolly S.J.
- Hallstrom A.P.
- Cappato R.
- et al.
- 7.We recommend use of an ICD for patients after cardiac arrest due to ventricular arrhythmias in the absence of a reversible cause (Strong Recommendation; High-Quality Evidence).
- 8.We suggest an ICD be considered after MI in the presence of sustained VT or VF > 48 hours after MI or > 48 hours after revascularization for MI in the absence of reversible causes (Weak Recommendation; Low-Quality Evidence). (Sustained VT refers to hemodynamically significant VT or VT > 30 seconds in duration.)
- 9.We recommend an ICD for patients with sustained VT in the presence of significant structural heart disease in the absence of reversible causes (Strong Recommendation; Moderate-Quality Evidence).

- 10.We suggest an ICD be considered in patients with significant structural heart disease and syncope of unknown origin for whom the cause of syncope is most likely VT/VF and in whom the risk of recurrent VT/VF is high (Weak Recommendation; Moderate-Quality Evidence).
- 11.We recommend an ICD for patients with syncope of unknown origin with inducible VT at the time of EPS and structural heart disease (Strong Recommendation; Moderate-Quality Evidence).
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Other Issues
Left ventricular assist devices and ICDs
Patients listed for heart transplantation
- 12.We suggest that ICDs be considered in patients with an LVAD (Weak Recommendation; Low-Quality Evidence).
- 13.We recommend that an ICD be implanted in outpatients who have been listed for cardiac transplantation (Strong Recommendation; Moderate-Quality Evidence).
Device Selection
Single vs dual-chamber devices

- 14.We suggest a single-chamber ICD instead of a dual chamber ICD in patients with no indication for atrial pacing and in whom the indication for ICD implantation is for the primary prevention of SCD due to ventricular arrhythmias (Weak Recommendation; Moderate-Quality Evidence).
ICD lead selection
- 15.We suggest a single-coil HV ICD lead is preferred over a dual-coil HV ICD lead at the time of implantation (Weak Recommendation; Moderate-Quality Evidence).
Site of ICD implantation
- 16.We recommend that transvenous ICDs be implanted on the left side as the first option for endovascular systems (Strong Recommendation; Moderate-Quality Evidence).
Subcutaneous ICDs
- 17.We recommend an S-ICD be considered in patients with limited vascular access or pocket sites in whom an ICD is recommended (Strong Recommendation; Low-Quality Evidence).
Other Considerations at the Time of Implant
Venous access
Prevention of infections
- Sandoe J.A.
- Barlow G.
- Chambers J.B.
- et al.
- 18.We recommend the use of comprehensive CIED infection prevention measures in all patients who undergo ICD insertion (Strong Recommendation; Moderate-Quality Evidence).
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Defibrillation testing at the time of implantation
- 19.We recommend that defibrillation safety margin testing not be performed for endovascular left-sided devices that are implanted for prevention of SCD due to ventricular arrhythmias in the absence of conditions known to increase the DFT (right-sided implants, hypertrophic cardiomyopathy, channelopathies, at the time of generator replacement when a lead is on advisory) or if detection of VF could be impaired (such as an unusual lead position or small R wave detection) (Strong Recommendation; High-Quality Evidence).
- 20.We suggest that defibrillator safety margin testing be considered at the time of implantation for right-sided implants and for patients with hypertrophic cardiomyopathy or channelopathies (Weak Recommendation; Low-Quality Evidence).
- 21.We recommend defibrillation safety margin testing for all subcutaneous defibrillation systems (Strong Recommendation; Moderate-Quality Evidence).
Anticoagulation
- 22.We recommend that ICD implantation should be performed with a therapeutic INR in patients who receive vitamin K antagonists with an estimated annual risk of embolic events ≥ 5%. For patients who receive vitamin K antagonists with an estimated annual risk of embolic events < 5%, we recommend ICD implantation be performed with a therapeutic INR or temporary discontinuation of a vitamin K antagonist (no bridging) (Strong Recommendation; High-Quality Evidence).
References
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Footnotes
The disclosure information of the authors and reviewers is available from the CCS on their guidelines library at www.ccs.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.