[Sudden cardiac death in structural heart disease : Update on prevention]

Sudden cardiac death (SCD) remains one of the leading causes of death despite major advances in cardiovascular diagnostics and treatment. Evidence supporting primary prophylactic implantable cardioverter defibrillator (ICD) implantation is still derived from trials conducted more than two decades ago and no longer reflects contemporary clinical practice. Modern heart failure treatment, improved coronary artery disease (CAD) management and refined prevention strategies have substantially reduced the risk of SCD and question the role of the left ventricular ejection fraction (LVEF) as the primary selection criterion. Recent studies further demonstrated that a universal survival benefit due to an ICD is absent in several patient groups previously considered to have a high risk. Current developments emphasize individualized risk stratification incorporating the overall risk, imaging-based markers such as scar architecture on cardiac magnetic resonance imaging (MRI), genetic variants, modifiable therapeutic factors and electrocardiographic parameters. In addition, artificial intelligence (AI)-based approaches offer new opportunities for risk prediction in both high-risk populations and the general population. Ongoing trials, such as PROFID-EHRA and CONTEMP-ICD are expected to fundamentally reshape the risk stratification and guideline recommendations. Until then, decisions regarding ICD implantation remain an interdisciplinary challenge.