title: Barriers to patients eligible for screening investigations and insertion of primary prevention implantable cardioverter defibrillators.
abstract: OBJECTIVE
  Primary prevention (PP) implantable cardioverter defibrillator (ICD) implant rates in the UK are below national targets and barriers to this are not well known. This study was designed to identify the stages along the referral pathway from general to specialist care that eligible patients reach and what proportion eventually receive an ICD.
  
  
  RESULTS
  A single institution database search was performed to identify all adults with severe left ventricular systolic dysfunction (left ventricular ejection fraction, LVEF≤35%), documented in the calendar year 2007. Medical records were assessed for age, heart failure aetiology, QRS duration, evidence of non-sustained ventricular tachycardia on Holter, electrophysiological study, and records of consultation with general physicians, cardiologists, and electrophysiologists (EPs) and reference to assessment of risk of sudden cardiac death and the role of ICD implantation. Three hundred twenty-six patients with LVEF ≤ 35% were identified from three electronic databases. Mean age was 72 ± 12 years. Seventy-two patients satisfied UK National Institute for Clinical Excellence guidelines for PP ICD implantation and 63 eligible for further screening. Of the 135 patients, 76 (56%) patients reviewed by a general cardiologist did not receive ICD implantation or referral for further assessment. When offered, ICD acceptance rate was high (35 vs. 3 patients who refused ICD). After seeing an EP, 8 of 47 (17%) patients were not offered ICD or further screening. The average age was 66.5 ± 6.2 years and no patient greater than 80 years had a PP ICD.
  
  
  CONCLUSIONS
  Failure to refer from the general physician to cardiology and from the cardiologist to EP is the principle reason for low PP ICD implant rates among eligible patients in the UK.
authors.affiliation: Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK.
authors.forename: Praveen P
authors.initials: PP
authors.lastname: Sadarmin
authors.affiliation: Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK.
authors.forename: Kelvin Ck
authors.initials: KC
authors.lastname: Wong
authors.affiliation: Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK.
authors.forename: Kim
authors.initials: K
authors.lastname: Rajappan
authors.affiliation: Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK.
authors.forename: Yaver
authors.initials: Y
authors.lastname: Bashir
authors.affiliation: Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK ep.doctors@ouh.nhs.uk.
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Betts
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D017147:Defibrillators, Implantable; D004554:Electric Countershock / Q000295:instrumentation*; D015716:Electrocardiography, Ambulatory; D022062:Electrophysiologic Techniques, Cardiac; D004608:Eligibility Determination; D004739:England; D005260:Female; D006297:Health Services Accessibility; D006333:Heart Failure / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D010349:Patient Compliance; D011237:Predictive Value of Tests; D011322:Primary Prevention / Q000295:instrumentation* / Q000379:methods; D012017:Referral and Consultation; D012307:Risk Factors; D013318:Stroke Volume; D062606:Tertiary Care Centers; D016312:Treatment Refusal; D016277:Ventricular Function, Left
keywords: Implantable cardioverter defibrillators; Primary prevention; Tertiary centre