Are We Implanting Too Many Primary-Prevention Implantable Cardioverter-Defibrillators?

Canadian Cardiovascular Society/Canadian Heart Failure Society guidelines recommend optimising patients with heart failure with reduced ejection fraction (HFrEF) on guideline-directed medical therapy (GDMT) before placing primary-prevention implantable cardioverterdefibrillators fi brillators (ICDs). However, GDMT is often suboptimal at the time of ICD placement, which is associated with reduced survival. Furthermore, with evidence for declining sudden cardiac death (SCD) rates in patients with cardiomyopathy, there is a need for better risk stratification fi cation to determine the indication for an ICD.1 1 This raises concern for potentially unnecessary ICD placement in this population, and efforts are needed to address this issue in clinical practice.