Abstract
The use of implantable cardioverter-defibrillators (ICDs) significantly reduces the
risk of mortality in patients with heart failure with reduced ejection fraction (HFrEF).
Current guidelines, which are based on seminal clinical trials published nearly 2
decades ago, recommend that patients be on optimal medical therapy for HF for a minimum
of 3 months before referral for prophylactic ICD. This waiting period allows for left
ventricular reverse remodelling and improvement in HF symptoms, which may render primary
prevention ICD implantation unnecessary. However, medical therapy for HFrEF has significantly
evolved since the publication of these landmark trials. Given the plethora of medical
therapy options now available for HFrEF, it is appropriate to reassess the duration
of this waiting period. In the present review, we examine the landmark randomised
trials in primary prevention of sudden cardiac death in patients with HFrEF, summarise
the novel medical therapies (sacubitril-valsartan, sodium-glucose cotransporter 2
inhibitors, ivabradine, vericiguat, and omecamtiv mecarbil) that have emerged since
the publication of those trials, discuss the optimal timing of ICD referral, and review
subtypes of nonischemic cardiomyopathy where timing of ICD insertion is guided by
alternative criteria. With the steps now needed to optimise medical therapy for HFrEF,
in terms of both classes of drugs and doses of each agent, it can easily take up to
6 months to achieve optimisation. Following that, waiting periods of 3 months for
ischemic cardiomyopathy and 6 months for nonischemic cardiomyopathy may be required
to allow adequate reverse remodelling before reevaluating for ICD implantation.
Résumé
Le recours à un défibrillateur cardioverteur implantable (DCI) réduit de manière significative
le risque de mortalité chez les patients présentant une insuffisance cardiaque avec
fraction d’éjection réduite (ICFER). Les lignes directrices actuelles, qui sont fondées
sur les résultats d’essais cliniques fondamentaux publiés il y a près de 20 ans, recommandent
de soumettre les patients à un traitement médical optimal contre l’insuffisance cardiaque
pendant au moins trois mois avant de les orienter vers un spécialiste pour la pose
d’un DCI prophylactique. Cette période d’attente permet le remodelage inverse du ventricule
gauche et donne le temps aux symptômes d’insuffisance cardiaque de s’atténuer, ce
qui pourrait rendre inutile la pose d’un DCI en prévention primaire. Les traitements
médicaux de l’ICFER ont toutefois beaucoup évolué depuis la publication de ces essais
phares. Compte tenu des très nombreuses options thérapeutiques maintenant offertes
pour le traitement de l’ICFER, il convient de réévaluer la durée de cette période
d’attente. Nous examinons ici les essais phares avec répartition aléatoire sur la
prévention primaire de la mort cardiaque subite chez les patients atteints d’ICFER;
nous présentons aussi un résumé des nouveaux traitements médicaux (association sacubitril-valsartan,
inhibiteurs du co-transporteur sodium-glucose de type 2 [SGLT2], ivabradine, vériciguat
et omécamtiv mécarbil) commercialisés depuis la publication de ces essais, traitons
du moment optimal pour l’orientation aux fins de pose d’un DCI et passons en revue
les sous-types de cardiomyopathie non ischémique pour lesquels le moment de la pose
d’un DCI dépend d’autres critères. En raison des étapes à franchir aujourd’hui pour
optimiser le traitement médical de l’ICFER, tant en ce qui concerne les classes de
médicaments que les doses de chacun des agents, cette optimisation peut facilement
prendre jusqu’à six mois. Par la suite, il peut être nécessaire d’attendre trois mois
(dans le cas d’une cardiomyopathie ischémique) ou six mois (dans le cas d’une cardiomyopathie
non ischémique) avant de réévaluer la nécessité de la pose d’un DCI, afin de permettre
un remodelage inverse adéquat.
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References
- The relationships among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction.Circulation. 1984; 69: 250-258
- EURObservational Research Programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot).Eur J Heart Fail. 2013; 15: 808-817
- Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure.N Engl J Med. 2005; 352: 225-237
- Multicenter Automatic Defibrillator Implantation Trial Investigators. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia.N Engl J Med. 1996; 335: 1933-1940
- Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction.N Engl J Med. 2002; 346: 877-883
- 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Circulation. 2018; 138: e272-391
- Canadian Cardiovascular Society/Canadian Heart Rhythm Society 2016 implantable cardioverter-defibrillator guidelines.Can J Cardiol. 2017; 33: 174-188
- 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36: 2793-2867
- Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy.N Engl J Med. 2004; 350: 2151-2158
- Primary prevention implantable cardioverter defibrillators in patients with nonischemic cardiomyopathy: a meta-analysis.JAMA Cardiol. 2017; 2: 685-688
- MOCHA Investigators. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure.Circulation. 1996; 94: 2807-2816
- 2017 comprehensive update of the canadian cardiovascular society guidelines for the management of heart failure.Can J Cardiol. 2017; 33: 1342-1433
- Valsartan benefits left ventricular structure and function in heart failure: Val-HeFT echocardiographic study.J Am Coll Cardiol. 2002; 40: 970-975
- Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.N Engl J Med. 2003; 348: 1309-1321
- Eplerenone in patients with systolic heart failure and mild symptoms.N Engl J Med. 2011; 364: 11-21
- Angiotensin-neprilysin inhibition versus enalapril in heart failure.N Engl J Med. 2014; 371: 993-1004
- Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study.Lancet. 2010; 376: 875-885
- Dapagliflozin in patients with heart failure and reduced ejection fraction.N Engl J Med. 2019; 381: 1995-2008
- Vericiguat in patients with heart failure and reduced ejection fraction.N Engl J Med. 2020; 382: 1883-1893
- Improving guideline adherence: a randomized trial evaluating strategies to increase beta-blocker use in heart failure.Circulation. 2003; 107: 2799-2804
- 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways.J Am Coll Cardiol. 2018; 71: 201-230
- 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur J Heart Fail. 2016; 18: 891-975
- Declining risk of sudden death in heart failure.N Engl J Med. 2017; 377: 41-51
- Multicenter Unsustained Tachycardia Trial Investigators. A randomized study of the prevention of sudden death in patients with coronary artery disease.N Engl J Med. 1999; 341: 1882-1890
- Coronary Artery Bypass Graft (CABG) Patch Trial Investigators. Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery.N Engl J Med. 1997; 337: 1569-1575
- Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction.N Engl J Med. 2004; 351: 2481-2488
- Defibrillator implantation early after myocardial infarction.N Engl J Med. 2009; 361: 1427-1436
- Primary prevention of sudden cardiac death in idiopathic dilated cardiomyopathy: the Cardiomyopathy Trial (CAT).Circulation. 2002; 105: 1453-1458
- Amiodarone versus implantable cardioverter-defibrillator:randomized trial in patients with nonischemic dilated cardiomyopathy and asymptomatic nonsustained ventricular tachycardia—AMIOVIRT.J Am Coll Cardiol. 2003; 41: 1707-1712
- Defibrillator implantation in patients with nonischemic systolic heart failure.N Engl J Med. 2016; 375: 1221-1230
- Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure.N Engl J Med. 2004; 350: 2140-2150
- Implantable cardioverter-defibrillator for nonischemic cardiomyopathy: an updated meta-analysis.Circulation. 2017; 135: 201-203
- Cardiovascular and renal outcomes with empagliflozin in heart failure.N Engl J Med. 2020; 383: 1413-1424
- Cardiac myosin activation with omecamtiv mecarbil in systolic heart failure.N Engl J Med. 2021; 384: 105-116
- Initiating sacubitril/valsartan (LCZ696) in heart failure: results of TITRATION, a double-blind, randomized comparison of two uptitration regimens.Eur J Heart Fail. 2016; 18: 1193-1202
- Improving medication titration in heart failure by embedding a structured medication titration plan.Int J Cardiol. 2016; 224: 99-106
- 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.J Am Coll Cardiol. 2016; 68: 1476-1488
- How can optimization of medical treatment avoid unnecessary implantable cardioverter-defibrillator implantations in patients with idiopathic dilated cardiomyopathy presenting with “SCD-HeFT criteria”?.Am J Cardiol. 2012; 109: 729-735
- Association of change in N-terminal Pro–B-type natriuretic peptide following initiation of sacubitril-valsartan treatment with cardiac structure and function in patients with heart failure with reduced ejection fraction.JAMA. 2019; 322: 1085-1095
- Effects of selective heart rate reduction with ivabradine on left ventricular remodelling and function: results from the SHIFT echocardiography substudy.Eur Heart J. 2011; 32: 2507-2515
- Effect of vericiguat on left ventricular function: the VICTORIA echocardiographic sub-study.Heart Failure Association Discoveries, 2020 webinar: June 5, 2020
- Use of the wearable cardioverter defibrillator in high-risk cardiac patients: data from the Prospective Registry of Patients Using the Wearable Cardioverter Defibrillator (WEARIT-II Registry).Circulation. 2015; 132: 1613-1619
- Compelling first-line drug and device therapies for the prevention of sudden death in patients with chronic heart failure and a reduced ejection fraction who are candidates for an implantable cardioverter-defibrillator.Circ Arrhythm Electrophysiol. 2019; 12e007430
- Effect of the angiotensin-receptor-neprilysin inhibitor LCZ696 compared with enalapril on mode of death in heart failure patients.Eur Heart J. 2015; 36: 1990-1997
- Association between use of primary-prevention implantable cardioverter-defibrillators and mortality in patients with heart failure: a prospective propensity score-matched analysis from the Swedish Heart Failure Registry.Circulation. 2019; 140: 1530-1539
- Survival of patients receiving a primary prevention implantable cardioverter-defibrillator in clinical practice vs clinical trials.JAMA. 2013; 309: 55-62
- Association between prophylactic implantable cardioverter-defibrillators and survival in patients with left ventricular ejection fraction between 30% and 35%.JAMA. 2014; 311: 2209-2215
- Long-term outcomes of implantable cardioverter-defibrillator therapy in the SCD-HeFT.J Am Coll Cardiol. 2020; 76: 405-415
- Reverse remodeling in heart failure—fact or fiction?.Eur Heart J Suppl. 2004; 6: D66-78
- Waiting period before implantable cardioverter-defibrillator implantation in newly diagnosed heart failure with reduced ejection fraction: a window of opportunity.Circ Heart Fail. 2017; 10e004478
- Sudden cardiac death prediction and prevention: report from a National Heart, Lung, and Blood Institute and Heart Rhythm Society Workshop.Circulation. 2010; 122: 2335-2348
- Sudden cardiac death risk stratification.Circ Res. 2015; 116: 1907-1918
- Myocardial fibrosis and the effect of primary prophylactic defibrillator implantation in patients with nonischemic systolic heart failure—DANISH-MRI.Am Heart J. 2020; 221: 165-176
- The diagnosis and evaluation of dilated cardiomyopathy.J Am Coll Cardiol. 2016; 67: 2996-3010
- Personalizing risk stratification for sudden death in dilated cardiomyopathy: the past, present, and future.Circulation. 2017; 136: 215-231
- Cardiac sarcoidosis.J Am Coll Cardiol. 2016; 68: 411-421
- 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy.Heart Rhythm. 2019; 16: e301-e372
- Arrhythmogenic cardiomyopathy.Circ Res. 2017; 121: 784-802
- 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy. The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2733-2779
- Clinical course and management of hypertrophic cardiomyopathy.N Engl J Med. 2018; 379: 655-668
- Ventricular arrhythmias in cardiac sarcoidosis.Circulation. 2018; 138: 1253-1264
- Granulomatous myocarditis in severe heart failure patients undergoing implantation of a left ventricular assist device.Cardiovas Pathol. 2014; 23: 17-20
- HRS expert consensus statement on the diagnosis and management of arrhythmias associated with cardiac sarcoidosis.Heart Rhythm. 2014; 11: 1305-1323
- Molecular mechanisms of arrhythmogenic cardiomyopathy.Nat Rev Cardiol. 2019; 16: 519-537
- Left-dominant arrhythmogenic cardiomyopathy: an under-recognized clinical entity.J Am Coll Cardiol. 2008; 52: 2175-2187
- Lamin and the heart.Heart. 2018; 104: 468-479
- The nuclear lamins: flexibility in function.Nat Rev Mol Cell Biol. 2013; 14: 13-24
- Primary prevention of sudden death in patients with lamin A/C gene mutations.N Engl J Med. 2006; 354: 209-210
- Implantable cardioverter-defibrillators in lamin A/C mutation carriers with cardiac conduction disorders.Heart Rhythm. 2013; 10: 1492-1498
- Phospholamban: a crucial regulator of cardiac contractility.Nat Rev Mol Cell Biol. 2003; 4: 566-577
- Phospholamban R14del mutation in patients diagnosed with dilated cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy: evidence supporting the concept of arrhythmogenic cardiomyopathy.Eur J Heart Fail. 2012; 14: 1199-1207
- Genetic deletion of arginine 14 in phospholamban causes dilated cardiomyopathy with attenuated electrocardiographic R amplitudes.Heart Rhythm. 2009; 6: 480-486
- Neuromuscular Disorders and the Role of the Clinical Electrophysiologist.JACC Clin Electrophysiol. 2017; 3: 1069-1079
- Truncating FLNC mutations are associated with high-risk dilated and arrhythmogenic cardiomyopathies.J Am Coll Cardiol. 2016; 68: 2440-2451
- Cardiac phenotypes in hereditary muscle disorders: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 2485-2506
- Management of cardiac involvement associated with neuromuscular diseases: a scientific statement from the American Heart Association.Circulation. 2017; 136: e200-e231
- Arrhythmias in the muscular dystrophies.Heart Rhythm. 2012; 9: 1890-1895
- Mechanisms of sustained ventricular tachycardia in myotonic dystrophy.Circulation. 1998; 98: 541-546
- Electrocardiographic abnormalities and sudden death in myotonic dystrophy type 1.N Engl J Med. 2008; 358: 2688-2697
- 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society.Circulation. 2019; 140: e333-e381
- Electrophysiological study with prophylactic pacing and survival in adults with myotonic dystrophy and conduction system disease.JAMA. 2012; 307: 1292-1301
- Predictors of atrio-ventricular conduction disease, long-term outcomes in patients with myotonic dystrophy types I and II.Pacing Clin Electrophysiol. 2012; 35: 1262-1269
Article info
Publication history
Published online: February 03, 2021
Accepted:
January 28,
2021
Received:
October 8,
2020
Footnotes
See page 651 for disclosure information.
Identification
Copyright
© 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
