title: Patient barriers to implantable cardioverter defibrillator implantation for the primary prevention of sudden cardiac death in patients with heart failure and reduced ejection fraction.
abstract: BACKGROUND
  Device therapy is efficacious in preventing sudden cardiac death (SCD) in patients with reduced ejection fraction. However, few who need the device eventually opt to undergo implantation and even fewer reconsider their decisions after deliberation. This is due to many factors, including unresolved patient barriers. This study identified the factors that influenced patients' decision to decline implantable cardioverter defibrillator (ICD) implantation, and those that influenced patients who initially declined an implant to reconsider having one.
  
  
  METHODS
  A single-centre survey was conducted among 240 patients who had heart failure with reduced ejection fraction and met the ICD implantation criteria, but had declined ICD implantation.
  
  
  RESULTS
  Participants who refused ICD implantation were mostly male (84%), Chinese (71%), married (72%), currently employed (54%), and had up to primary or secondary education (78%) and monthly income of < SGD 3,000 (51%). Those who were more likely to reconsider their decision were aware that SCD was a consequence of heart failure with reduced ejection fraction, knowledgeable of the preventive role of ICDs, currently employed and aware that their doctor strongly recommended the implant. Based on multivariate analysis, knowledge of the role of ICDs for primary prophylaxis was the most important factor influencing patient decision.
  
  
  CONCLUSIONS
  This study identified the demographic and social factors of patients who refused ICD therapy. Knowledge of the role of ICDs in preventing SCD was found to be the strongest marker for reconsidering ICD implantation. Measures to address this information gap may lead to higher rates of ICD implantation.
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Laura Lihua
authors.initials: LL
authors.lastname: Chan
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Choon Pin
authors.initials: CP
authors.lastname: Lim
authors.affiliation: Health Services Research, Eastern Health Alliance, Singapore.
authors.forename: Soe Tin
authors.initials: ST
authors.lastname: Aung
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Paul
authors.initials: P
authors.lastname: Quetua
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Kah Leng
authors.initials: KL
authors.lastname: Ho
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Daniel
authors.initials: D
authors.lastname: Chong
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Wee Siong
authors.initials: WS
authors.lastname: Teo
authors.affiliation: Department of Cardiology, National Heart Centre Singapore.
authors.forename: David
authors.initials: D
authors.lastname: Sim
authors.affiliation: Department of Cardiology, National Heart Centre, Singapore.
authors.forename: Chi Keong
authors.initials: CK
authors.lastname: Ching
mesh_terms: D003430:Cross-Sectional Studies; D016757:Death, Sudden, Cardiac / Q000517:prevention & control*; D017147:Defibrillators, Implantable; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011322:Primary Prevention / Q000379:methods*; D012307:Risk Factors; D012846:Singapore / Q000453:epidemiology; D013318:Stroke Volume / Q000502:physiology*; D015996:Survival Rate / Q000639:trends
keywords: barriers; heart failure; implantable cardioverter defibrillator