Worldwide utilization of implantable cardioverter/defibrillators now and in the future

Despite the demonstrated efficacy of implantable cardioverter defibrillators (ICDs) in reducing sudden and total mortality in selected patients, their implantation rates vary greatly between countries. In the United States, implantation rate is 228 implants per million inhabitants compared to only 45 implants per million in Western Europe. The differences in the ICD use may be explained by 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.