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The burden of inappropriate shocks in young people and how to avoid them
  1. Gaurav A Upadhyay,
  2. Theofanie Mela,
  3. Jagmeet P Singh
  1. Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Jagmeet P Singh, Cardiac Arrhythmia Service, Massachusetts General Hospital Heart Center, Gray Building 109, 55 Fruit Street, Boston, MA 02114, USA; jsingh{at}

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Implicated in up to half of all cardiovascular mortality among developed nations worldwide,w1 w2 sudden cardiac death (SCD) is associated with approximately 450 000 deaths annually in the USA and >700 000 deaths in Europe.w3 w4 In 23% of out-of-hospital and 17% of inhospital cardiac arrests, the initial observed rhythm was ventricular tachycardia (VT) or ventricular fibrillation (VF), both potentially treatable with defibrillation.w5 w6 Large scale trials have also demonstrated that implantable cardioverter defibrillators (ICDs) can improve survival through terminating malignant ventricular arrhythmias, particularly among SCD survivorsw7 and heart failure patients with systolic dysfunction.w8–w12 Based on these data, there has been a dramatic surge in the utilisation of ICDs over the past two decades, with 116 000 ICD device implantations in the USA in 2009 alone, of which 53 000 (46%) were implanted in patients younger than the age of 65 years.w6

With increasing use of ICDs, there has also been heightened awareness of device-related complications and associated risk–benefit trade-offs. Specifically, although it is clear that appropriate ICD therapies extend survival, inappropriate ICD shocks are common and occur in a similar magnitude of patients.w12 w13 Frequent ICD shocks are associated with diminished quality of life,w14 w15 and significant anxiety, depression and post-traumatic stress in a minority of patients.w16 w17 In addition, inappropriate ICD shocks have been linked to the possibility of proarryhthmiaw18–w20 and are associated with increased mortality in some patients, although any causal relationship remains controversial.1–3 w21–w23 Conversely, interventions to prevent inappropriate ICD shocks reduce morbidity,4 and also have been shown to reduce heart failure hospitalisation.5

As the use of ICDs continues to expand further into primary prevention and younger patient populations, identifying at-risk patients and devising a treatment plan for patients suffering from inappropriate shocks are critical. Strategies to avoid inappropriate …

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  • Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. Dr Upadhyay received salary support from the 2011 Max Schaldach Fellowship in Cardiac Pacing and Electrophysiology of the Heart Rhythm Society. Dr Mela reports speaker's honoraria from Boston Scientific Corp, Medtronic Inc, and St Jude Medical. Dr Singh reports receiving research grants from St Jude Medical, Medtronic Inc, Boston Scientific Corp and Biotronik. He also serves on advisory boards or as a consultant for Boston Scientific Corp, St Jude Medical, Sorin Group, CardioInsight Inc, Respicardia Inc and Medtronic Inc. Finally, he has received speaker's honoraria from Medtronic Inc, Biotronik, Boston Scientific Corp, St Jude Medical and the Sorin Group.

  • Provenance and peer review Commissioned; internally peer reviewed.