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Should patients with heart failure who require an implantable cardiac defibrillator (ICD) get a device capable of delivering cardiac resynchronisation therapy (CRT-D) routinely? For those that like to read the conclusions first, the answer is “yes”. It is difficult to justify implanting only a defibrillator in anyone who has heart failure and an indication for an ICD. Most of these patients should get a CRT-D device.
This conclusion might seem odd at first but the arguments are quite straightforward. National Institute for Health and Clinical Excellence (NICE) guidelines1 suggest that patients with heart failure as a result of ischaemic heart disease (IHD) should get an ICD if their left ventricular ejection fraction (LVEF) is <35% and they also have non-sustained ventricular tachycardia (NSVT) on ambulatory electrocardiographic monitoring and inducible ventricular tachycardia (VT) on electrophysiological monitoring, provided that the patient is not in end-stage heart failure and is not within one month of a myocardial infarction. Alternatively, in patients with an LVEF, less than 30% patients without end-stage heart failure who have a QRS interval >120 ms, should receive an ICD. NICE has not yet issued guidance on defibrillators for patients with heart failure from causes other than IHD. The LVEF criteria are based on evidence from clinical trials in patients receiving contemporary pharmacological therapy (fig 1).2–4
The NSVT criterion is based on a moderate amount of evidence acquired in the era before widespread use of β-blockers that suggested a higher mortality in such patients, although not necessarily from arrhythmias.5 6 The prevalence of NSVT will vary according to the extent of ventricular disease, the duration of monitoring and the quality of heart failure management, but it may be present in the majority of patients.5 Amino-terminal pro-brain natriuretic peptide is a much more robust, …