Despite the demonstrated efficacy of implantable cardioverter defibrillators (ICDs) in reducing sudden and total mortality in selected patients, their implantation rates vary greatly among countries. In the United States, the implantation rate is 185 implants per million inhabitants compared with only 31 implants per million in western Europe. The differences in ICD use may be explained by the following factors: manner in which sudden cardiac death is perceived by politicians and physicians (sudden cardiac death is perceived as a "nice way of dying"); differences in indications; physicians' information; prevalence of coronary artery disease; sudden cardiac death survival rates; perceived reliability of alternative treatment (namely, antiarrhythmics including amiodarone); economic backgrounds; and health care politics. Furthermore, the cost of this treatment strategy must be considered. This issue has been raised because generalization of ICD use in patients matching clinical characteristics of patients enrolled in the primary prevention trials may represent a significant economic burden to be added to the already overloaded health care system. This low acceptance may not be entirely related to budget constraint but also to the perceived efficacy of ICDs by physicians and health authorities.