Guideline-Directed Medical Therapy Underused in HFrEF Patients Before ICD

4. S-ICD Therapy
4. S-ICD Therapy
Patients with heart failure with reduced ejection fraction who received any guideline-directed medical therapy were less likely to die within 1 year of implantable cardioverter-defibrillator placement.

Guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) before primary prevention implantable cardioverter-defibrillator (ICD) placement was underused, according to a study published in the Journal of the American College of Cardiology.

Researchers examined data from the National Cardiovascular Data Registry ICD Registry combined with a 40% random sample of Medicare data between 2007 and 2011. Guideline-directed medical therapy was defined as at least 1 prescription filled for both an HF-approved beta-blocker and any rennin-angiotensin inhibitor 90 days prior to ICD implantation.

Of the 19 733 patients, 61.1% filled prescriptions for guided-directed medical therapy. In addition, of that 61.1%, only one-half received an adequate supply to cover 80% of the 90 days before the implantation. Researchers observed broad variations in levels of care across the health referral regions, ranging from 16% to 49%.

Most importantly, patients who received any pre-implantation guideline-directed medical therapy were less likely to die within 1 year of implantation compared with those who received none (11.1% vs 16.2%). Even after adjusting for individual characteristics, comorbidities (eg, cerebrovascular disease, COPD, chronic renal disease, dementia, and diabetes), and HF severity, patients who filled prescriptions were still less likely to die within 1 year (adjusted relative risk: 0.80; 95% confidence interval: 0.73-0.87).

Lack of chronic renal disease or nonsustained ventricular tachycardia, low-income prescription benefits subsidy, and less recent left ventricular ejection fraction evaluation were considered the strongest predictors of guided-directed medical therapy.

“Rates of GDMT [guideline-directed medical therapy] for HFrEF before implantation of primary prevention ICDs were low in this Medicare population, and failure to achieve GDMT were associated with significantly decreased survival within the first year after ICD implantation,” researchers concluded. “When not contraindicated, patients with HFrEF should receive GDMT before implantation of an ICD for the primary prevention of ventricular arrhythmic death.”

More studies should be conducted to examine the interaction between pharmaceutical and device therapies, particularly for elderly patients with HRrEF.


Roth GA, Poole JE, Zaha R, Zhou W, Skinner J, Morden NE. Use of guideline-directed medications for heart failure before cardioverter-defibrillator implantation. JACC. 2016;67(9):1062-1069. doi: 10.1016/j.jacc.2015.12.046.