Waiting Period Before Implantable Cardioverter-Defibrillator Implantation in Newly Diagnosed Heart Failure With Reduced Ejection Fraction
A Window of Opportunity
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A critical waiting period of ≈3 months is generally accepted in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) outside the context of an acute myocardial infarction before reassessing left ventricular (LV) ejection fraction and considering implantable cardioverter-defibrillator (ICD) therapy. This time window is offered to allow optimization of guideline-directed medical therapy (GDMT) to promote LV reverse remodeling, which if above a certain threshold, would render the need for an ICD unnecessary. Consideration for an ICD after this time-frame is endorsed by major professional groups,1 serves as a key quality and performance measure, and is deemed appropriate by the Appropriate Use Criteria for ICD therapy.2 This duration also guides reimbursement schema, for example, the Centers for Medicare & Medicaid Services limit coverage for ICDs in nonischemic dilated cardiomyopathy to after this 3-month waiting period.
Perhaps it is time to lengthen this time-frame before ICD decision making in newly diagnosed patients with HFrEF. In many cases, 3 months are not sufficient to truly optimize GDMT and allow adequate chance for LV recovery. Evolving risks of sudden cardiac death (SCD), recent expansion of the heart failure (HF) therapeutic armamentarium, and greater focus on shared decision making all support extension of this time window. We summarize these converging lines of evidence and critically appraise the merits of extending this traditional waiting period. We contend that consideration for ICD implantation should only occur once GDMT has been achieved at target doses and may be deferred up to 1 year after diagnosis in appropriately selected patients. As the Centers for Medicare & Medicaid Services plan to update the national coverage determination regarding ICD implantation over the next year, we believe this issue is timely and topical to address.
Landscape of Sudden Cardiac Death
Epidemiological studies3 and clinical trials4 during the past several decades …