Low referral rate for prophylactic implantation of cardioverter-defibrillators in a tertiary care medical center.
BACKGROUND
Implantable cardioverter-defibrillators (ICDs) for primary prevention became standard of care after the publication of the second Multicenter Automatic Defibrillator Implantation Trial (MADIT-II) and Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT).


OBJECTIVE
To determine the percentage of patients in a Veterans Affairs medical center appropriately referred for primary prophylaxis ICD and to further categorize the reasons patients are not being referred.


METHODS
Echocardiograms obtained since the release of MADIT-II in 2002 were searched for a left ventricular ejection fraction (LVEF) < or = 35% and < or =30%. We randomly selected 120 patients per year from 2002 to 2006, for a total of 600 patients in each group. Data were reviewed to determine the number of ICD recipients and the reasons patients were not referred.


RESULTS
In the LVEF < or = 35% group an ICD was implanted in 28% of 392 eligible patients. Nonreferral (58%) was the most common reason that eligible patients did not receive an ICD. Patients were not referred for ICD because of appropriate contraindications in 26% of cases. Overall mortality was 29% (15% with and 31% without ICD). In the LVEF < or =30% group an ICD was implanted in 33% of 388 eligible patients. Nonreferral (51%) was the most common reason that eligible patients did not receive an ICD. Patients were not referred for ICD because of appropriate contraindications in 24% of cases. Overall mortality was 28% (18% with and 32% without ICD).


CONCLUSIONS
After the publication of MADIT-II and SCD-HeFT, only 42% of eligible patients with LVEF < or = 35% and 49% of patients with LVEF < or =30% were offered a potentially life-saving ICD between 2002 and 2006 in our medical center, sometimes with considerable delay.
Bradfield
Jason
J
VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
Warner
Alberta
A
Bersohn
Malcolm M
MM
D000368:Aged; D002140:California / Q000453:epidemiology; D017147:Defibrillators, Implantable / Q000706:statistics & numerical data*; D004554:Electric Countershock / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D018579:Patient Selection; D015995:Prevalence; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016019:Survival Analysis; D015996:Survival Rate; D018487:Ventricular Dysfunction, Left / Q000401:mortality* / Q000517:prevention & control*