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Primary prevention ICDs: why replace them if they haven't been used?
  1. Paul R Roberts
  1. Correspondence to Paul R Roberts, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO 16 6DY, UK; paul.roberts{at}uhs.nhs.uk

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The use of implantable cardioverter defibrillators (ICD) is widely accepted in current clinical practice and well recognised in published guidelines by international societies. The rate of uptake of this therapy continues to increase globally and particular in emerging/developing countries. It is well recognised that ICD therapy is expensive and carries a significant associated clinical burden. This clinical burden includes device infection, inappropriate shock therapy and device/lead failure. Consequently, there has been great endeavour to improve our risk stratification of patients at risk of sudden cardiac death, and so reduce the number of patients with ICDs that never receive therapy. Much of this focus has been targeted at the point of original implantation. However, it would seem logical to review this decision on an ongoing basis. The appropriate time to do this would be at the point of device replacement for battery depletion.

Cost efficacy analyses have consistently demonstrated that as a therapy it is considered cost effective. Market forces have, over the last decade, driven down the cost of ICDs. Many of these analyses were based upon the therapy in its early adoption and did not always factor in the long-term ongoing need for ICD replacement. A recent review of the data on cost effectiveness of ICD therapy continues to support its place as a mainstream therapy indicating its cost effectiveness to be comparable to that of renal dialysis (US$30 000–$50 000 per life-year saved).1 Dialysis has commonly been used as a benchmark for cost effectiveness.

Early landmark studies demonstrated that ICDs were an effective strategy for the primary prevention of sudden cardiac death in individuals deemed to be at risk. The …

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