Cardioverter‐defibrillators after MADIT‐II: the balance between weight of evidence and treatment costs

Abstract

The possibility of using implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death in selected highrisk patients has prompted a series of prospective controlled studies. Recently, the MADIT II study highlighted the possibility of effective primary prevention of sudden death in patients with coronary artery disease selected by straightforward clinical data and without expensive screening (electrophysiological study). For patients with previous myocardial infarction and low left ventricular ejection fraction ((30%), ICD implantation may reduce mortality risk by approximately 31% in the following 2 years. Implementation of this therapeutic strategy threatens to impact on public health-care spending. Possible cost-limiting mechanisms include price cuts because of increasing usage (market forces); identification of subgroups at higher risk of sudden death and use of cheaper devices with limited diagnostic and therapeutic options. Further long-term evaluation of the cost-effectiveness and cost-utility of ICDs should identify subgroups of patients for whom implantation is affordable despite current economic constraints. For heart failure patients, randomized controlled trials are currently evaluating the effects on overall survival of both conventional ICDs and devices with biventricular pacing capabilities. In this perspective, data from the COMPANION trial are expected to stimulate the use of devices with defibrillation back-up in candidates for biventricular pacing.

Trial‐generated profiles for implantation of electrical devices in outpatients with heart failure: real‐world prevalence and 1‐year outcome

“…Especially in European countries, guideline implementation is complicated by the affordability of device therapy, an economic issue of obvious public health relevance [7]. Investigation of prevalence of the trial‐generated profiles in ‘real‐world’ clinical practice could provide relevant information for public health policy makers [8].…”

Letter Regarding Article by Bokhari et al, “Long-Term Comparison of the Implantable Cardioverter Defibrillator Versus Amiodarone: Eleven-Year Follow-Up of a Subset of Patients in the Canadian Implantable Defibrillator Study (CIDS)”

“…1,2 The interesting study by Bokhari et al 3 of the long-term efficacy of ICDs in clinical practice has relevant economic implications that the authors did not discuss.…”

Frequent Home Monitoring of ICD Is Effective to Prevent Inappropriate Defibrillator Shock Delivery

“…Recently, there is a growing interest also in the remote monitoring and followup of implantable cardioverter defibrillators (ICDs). The number of patients with implantable devices has been growing steadily, mainly because indications for ICD shifted from secondary to primary prevention of sudden death [4] (for more details refer to Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) [5]).…”