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Published on: June 11, 2012
Application of ICD guidelines and indications in a community-based academic hospital: a case series-based discussion
Wuqiang Fan1, Koroush Khalighi2
1Department of Medicine, Easton Hospital, Easton, PA, USA ; School of Medicine, Drexel University, Philadelphia, PA, USA.
Insights
This study established hospital-wide criteria for implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) to standardize patient care. These guidelines ensure appropriate device implantation, improving cost-effectiveness and resource utilization for sudden cardiac death prevention.
Area of Science:
- Cardiology
- Medical Device Technology
- Clinical Guidelines
Background:
- Implantable cardioverter defibrillators (ICDs) have demonstrated efficacy in selected patients since the 1980s.
- The need for systematic patient stratification and hospital-wide criteria for appropriate ICD implantation became evident.
- Evolving clinical evidence necessitated standardized approaches to device selection and implantation.
Purpose of the Study:
- To develop institution-wide inclusion and exclusion criteria for ICD and cardiac resynchronization therapy (CRT) implantation.
- To translate current clinical studies and guidelines into a practical standard of care.
- To address special clinical situations and patient populations not adequately covered by existing randomized controlled trials.
Main Methods:
- A comprehensive review of major ICD/CRT clinical studies and relevant guidelines was conducted.
- Institution-wide inclusion and exclusion criteria for ICD/CRT were formulated.
- A retrospective analysis of selected cases was performed to illustrate the application of these criteria.
Main Results:
- Standardized, practical, and up-to-date ICD inclusion and exclusion criteria were established for hospital practice.
- Thirteen representative cases highlighted major indications and contraindications for ICDs, including primary and secondary prevention of sudden cardiac death (SCD).
- The criteria addressed CRT for heart failure with prolonged QRS duration and explored benefits in special populations (elderly, female, alcoholic, ESRD/HD patients), alongside risks, complications, and wearable defibrillator use.
Conclusions:
- The established ICD/CRT criteria facilitate the practical translation of emerging therapies into clinical practice.
- Standardization of patient care and improved cost-effectiveness were achieved through these criteria.
- Appropriate utilization of institutional and device resources was enhanced by the developed guidelines.
Background:
Implantable cardioverter defibrillators (ICDs) are indeed beneficial in selected patients as evidenced by multiple large randomized controlled trials (RCTs) since 1980. A systematic method for stratification of patients and hospital-wide criteria/guidelines to ascertain appropriate device implantation became necessary.
Methods:
Major ICD/CRT (cardiac resynchronization therapy) clinical studies and relevant guidelines were reviewed, and an institution-wide inclusion and exclusion criteria for ICD/CRT was formulated. A retrospective analysis of selected cases was performed to discuss the criteria and special clinical situations.
Results:
We have translated the evolving ICD/CRT studies into a standard of care at our hospital by formulating a standard, practical, and update-to-date ICD inclusion and exclusion criteria. Thirteen cases were selected to represent major indications and contraindications of ICDs in our practice. These cases cover indications of ICD for secondary prevention of sudden cardiac death (SCD), primary prevention of SCD in patients with CHF resulted from either ischemic or non-ischemic cardiomyopathy, as well as for infiltrative cardiomyopathy and inherited conditions. We discussed the application of CRT in patients with CHF associated with prolonged QRS duration. We then covered the potential benefits of ICD with/without CRT in certain special populations of patients that have not been adequately evaluated by currently available RCTs; these include alcoholic, elderly, female, and ESRD/HD patients. Finally, we addressed risks, complications and contraindications of ICD, as well as application of an external wearable defibrillator in AMI, or status post-CABG patient during the mandatory waiting period for an ICD.
Conclusions:
Establishment of the ICD/CRT criteria represents a practical translation of emerging CRTs and helps to standardize patient care in our hospital. It also improves cost-effectiveness as well as appropriate utilization of institute and device resources.
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