title: Outcomes in heart failure patients referred for consideration of implantable cardioverter defibrillator for primary prophylaxis of sudden cardiac death: what are the risks of waiting?
abstract: BACKGROUND
  Clinical trials have confirmed that implantable cardioverter defibrillators (ICDs) reduce mortality in patients with a left ventricular ejection fraction below 30%. The 'real-world' prognosis before ICD implantation in such patients is not known. The estimated risk of death is 0.8% per month, and this forms the basis for wait-time recommendations.
  
  
  OBJECTIVE
  To determine the consequences of waiting for ICD implantation among heart failure patients eligible for primary prophylactic ICD.
  
  
  METHODS
  The present retrospective study evaluated consecutive patients who were deemed eligible for primary prophylactic ICD implantation. Survival outcomes were tracked for patients who declined an ICD, those who accepted and received an ICD, and patients who accepted an ICD but died while waiting.
  
  
  RESULTS
  Of 470 patients referred for evaluation, 218 were deemed eligible for an ICD. A total of 174 of 218 patients (79.8%) accepted an ICD; 39 (17.9%) declined, and five (2.3%) were deemed to be at too great a risk for the procedure. The mortality rate at two years among patients who accepted an ICD was 18.8% before ICD implantation and 12.2% after ICD implantation. Among patients who declined ICD implantation, the two year mortality rate was 5.3%. Among patients waiting for an ICD, five of 19 deaths were out-of- hospital sudden deaths. Of 12 patients who died after ICD implantation, there were no documented out-of-hospital sudden deaths.
  
  
  CONCLUSIONS
  Consistent with current estimates, the mortality rate at two years among patients who accepted and were waiting for an ICD implant was 18.8%. After receiving an ICD, the mortality rate was 12.2% at two years.
authors.affiliation: Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Canada.
authors.forename: Nina
authors.initials: N
authors.lastname: Ghosh
authors.forename: Iqwal
authors.initials: I
authors.lastname: Mangat
authors.forename: Suzan S
authors.initials: SS
authors.lastname: O'Donnell
authors.forename: Arnold
authors.initials: A
authors.lastname: Pinter
authors.forename: Victoria
authors.initials: V
authors.lastname: Korley
authors.forename: Chris
authors.initials: C
authors.lastname: Lane
authors.forename: Paul
authors.initials: P
authors.lastname: Dorian
mesh_terms: D000368:Aged; D002423:Cause of Death; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000295:instrumentation*; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D012307:Risk Factors; D013318:Stroke Volume / Q000502:physiology; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology