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THE PROFILE OF THE HEART FAILURE PATIENT WHO DOESN’T BENEFIT FROM AN ICD. Giosuè Mascioli, MD, FESC Humanitas Gavazzeni - Bergamo. Death in Heart Failure. Possible role of ICD. ICD. ICD ?. Modified from: Henkel DM, Circ Heart Fail, Jul 2008. ICD benefit is not homogeneous.

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The profile of the heart failure patient who doesn t benefit from an icd

  • Giosuè Mascioli, MD, FESC

  • Humanitas Gavazzeni - Bergamo

Death in heart failure
Death in Heart Failure

Possible role

of ICD



Modified from: Henkel DM, Circ Heart Fail, Jul 2008

Icd benefit is not homogeneous
ICD benefit is not homogeneous

VHR: BUN ≥ 50 mg/dl and serum creatinine ≥ 2.5 mg/dl

Goldenberg I, JACC Jan 2008

Greater or lesser benefit
Greater or lesser benefit

Burden of cardiovascular illness



Magnitude of benefit (lower

number needed to treat)

Low risk of SD

Low overall

risk of death

High risk of SD

Intermediate overall

risk of death

Intermediate risk of SD

High overall

risk of death

The deadly duo
The deadly duo

Goldenberg I, Circulation Jun 2006

Icd therapy and competing death
ICD therapy and Competing Death

First appropriate ICD therapy

Death before first appropriate ICD therapy

Koller MT, Circulation Apr 2008

Icd and comorbidities
ICD and Comorbidities

Bruch C, Europace Sep. 2007

The sickest the worst 1

  • Analysis of MADIT 2 patients:

    • Mutivariate analysis of predictor of mortality:

      • Age > 65 yrs

      • NYHA class III - IV

      • AF

      • Increased level of BUN

Cygankiewicz I, Heart Rhythm Apr 2009

The sickest the worst 2

BMI < 26

Schernthaner C, Croat Med Journ 2007

Reverse epidemiology and acute hf
Reverse epidemiology and acute HF

Burger AJ, Int J Cardiol Mar 2008

Bmi and unadjusted all cause mortality
BMI and unadjusted all-cause mortality

Curtis JP, Arch Intern Med 2005

Importance of number of hf episodes
Importance of number of HF episodes

Setoguchi S, CMAJ Mar 2009

Badly treated worst prognosis 1
Badly treated,worst prognosis- 1

  • In MADIT 2, use of ICD was associated with a significant 39% increase in risk of HF

  • Risk can be reduced used the corrected therapy:

    • With B-blockers + ACE-inhibitors HR 0.36

    • With B-blockers only HR 0.51 (metoprolol 0.49, carvedilol 0.48)

    • With ACE-inhibitors only HR 0.64 (p NS)

Pietrasik G, JCE Apr. 2009

Badly treated worst prognosis 2
Badly treated,worst prognosis- 2

Gardiwal A, Europace Oct 2008

Predictors of late mortality in icd patients
Predictors of late mortality in ICD patients

Thibodeau JB, Am J Cardiol Mar 2008

Icd and kidney disease
ICD and kidney disease



* At standard procedural mortality. At procedural mortality rates increased,

age thresholds for ICD implant decrease.

Amin MS, JCE Dec. 2008

Icd and egrf
ICD and eGRF

Goldenberg I, Am J Cardiol Aug 2006

Cause specific mortality in icd patients evadef study 2
Cause-specific mortality in ICD patients: evadef study - 2

  • Among characteristics at implantation:

    • EF < 30% and history of AF related to SCD

    • Age, NYHA class, systemic HT, QRS duration, EF < 30% and lack of B-blockers related to HF death

    • An EF < 30% at implant appears to be the most important predictor of ICD-unresponsive SCD

Marijon E, Am Heart J Feb 2009

Age and icds 1
Age and ICDs- 1

Healey JS, Eur Heart J Feb 2007

Age and icds 2
Age and ICDs- 2

Cause - specific mortality rates

Healey JS, Eur Heart J Feb 2007

Conclusions 1
Conclusions - 1

  • We MUST keep in mind that we do not use ICD to reduce sudden death, but to reduce TOTAL mortality

  • If we cannot reach this goal, to implant an ICD is absolutely USELESS (if not negative for the patient)

  • The problem is: how I identify patients whose greater risk is to die of non cardiac cause of of HF ?

Conclusions 2
Conclusions - 2

  • Predictors od adverse prognosis in HF can be used to identify patients whose prognosis do not deserve an ICD

  • Among this factor we can recognize: non optimal drug therapy, too low EF, comorbidities, AF, low BMI and - particularly - kidney function

  • Score tables can be of some help in taking the right decision, together with good clinical sense

The profile of the heart failure patient who doesn t benefit from an icd

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Febrary 10, 2004

And the final comment
... and the final comment

I’ve stopped smoking. My life will be one week longer.

And that week will rain all the time!

Woody Allen