Reassessing the need for primary prevention implantable cardioverter-defibrillators in contemporary patients with heart failure

The main function of the implantable cardioverter-defibrillator (ICD) is to protect against sudden cardiac death (SCD) due to ventricular tachyarrhythmia (VTA). Current guidelines provide a recommendation to implant a prophylactic ICD for the primary prevention of SCD in individuals having heart failure with reduced ejection fraction (HFrEF) who never experienced a previous sustained VTA. However, these recommendations are based on clinical trials conducted more than 20 years ago and may not be applicable to contemporary patients with HFrEF who have a lower arrhythmic risk as a result of advances in heart failure medical therapies. Thus, there is an unmet need for more appropriate selection of contemporary patients with HFrEF for a primary prevention ICD. In this article, we review data underlying the current clinical equipoise on the need for routine implantation of a primary prevention ICD in patients with HFrEF and the rationale for conducting clinical trials that aim to reassess the role of the ICD in this population.