• Indications for ICD therapy

• Secondary prevention  — Implantation of an ICD is recommended for the

secondary prevention of VT/VF in the following settings
• Patients with a prior episode of resuscitated VT/VF or sustained
hemodynamically unstable VT in whom a completely reversible cause cannot
be identified. This includes patients with a variety of underlying heart diseases
and those with idiopathic VT/VF and congenital long QT syndrome,
but not patients who have VT/VF limited to the first 48 hours after an acute MI.
• Patients with episodes of spontaneous sustained VT in the presence of heart
disease (valvular, ischemic, hypertrophic, dilated, or infiltrative
cardiomyopathies) and other settings (eg, channelopathies).
• Primary prevention  — Implantation of an ICD is recommended for the primary
prevention of VT/VF in patients at risk of SCD due to VT/VF who have optimal
medical management (including use of beta blockers and ACE inhibitors),
including:
• Patients with a prior myocardial infarction (at least 40 days ago) and left
ventricular ejection fraction ≤30 percent.
• Patients with a cardiomyopathy, New York Heart Association functional class II to
III , and left ventricular ejection fraction ≤35 percent. Patients with a nonischemic
cardiomyopathy generally require optimal medical therapy for three months with
documentation of persistent left ventricular ejection fraction ≤35 percent at that
time. It is recommended that patients be evaluated at least three months after
revascularization (CABG or stent placement)
• Some patients with heart failure who are candidates for an ICD also
have intraventricular conduction delay (≥120 ms) and are candidates
for cardiac resynchronization therapy with a biventricular pacemaker.
Such patients could be treated with a device with combined ICD and
biventricular pacing functions
• Patients with syncope who have structural heart disease and
inducible VT/VF on electrophysiology study.
• Select patients with certain underlying disorders who are deemed to be
at high risk for life-threatening VT/VF. This includes:
• Patients with congenital long QT syndrome who have recurrent
symptoms or torsades de pointes despite therapy with beta blockers.
• High-risk patients with hypertrophic cardiomyopath
• High-risk patients with Brugada syndrome.
• High-risk patients with arrhythmogenic right ventricular cardiomyopathy.
• ELEMENTS OF THE ICD  — The ICD system is comprised of three
elements :
• Pacing/sensing electrodes
• Defibrillation electrodes
• Pulse generator
• The risk of SCD is highest during and immediately after an infarction,
then declines in phases over the following days and months. One-
quarter of arrhythmic deaths occur in the first three months and one-
half within the first year after an MI 
• High-risk patients  — A number of clinical features have been evaluated as a
means for identifying patients at the greatest risk of SCD following an acute
MI. These include:
• Spontaneous ventricular premature beats (VPBs) and nonsustained
ventricular tachycardia (NSVT)
• Reduced LV ejection fraction (LVEF)
• Late potentials on a signal averaged ECG (SAECG)
• Ventricular tachycardia (VT) induced by electrophysiologic study (EPS)
• Reduced heart rate variability (HRV)
• Microvolt T wave (repolarization) alternans (TWA)
• Timing  — When considering ICD placement for primary prevention in
a patient with a prior myocardial infarction, timing in relation to two
events is important:
• Time since the most recent myocardial infarction – Although the risk
of arrhythmic events is highest in the first days and weeks after an MI,
early ICD therapy (ie, within 40 days of the MI) did not improve
mortality in the two randomized trials that directly addressed this
question. The MADIT-II substudy also suggested that survival benefit
in patients receiving ICD was greater in patients whose index MI was
more remote
• Time since the most recent revascularization procedure – ICD
implantation for primary prevention of SCD is not recommended until
at least three months after a revascularization procedure. This
recommendation is based primarily upon the exclusion of such
patients from the ICD trials, suggesting that the results of these trials
may not apply to such patients. Furthermore, in a post-hoc analysis
from the MADIT II trial, benefit from ICD therapy was only seen in
those patients enrolled more than six months after a revascularization
procedure 
• General ICD indications  — According to the
2008 ACC/AHA/HRS guidelines, the following basic criteria are
required before ICD therapy should be considered:
• LV dysfunction due to a prior MI (only applies to patients with
ischemic heart disease as their indication for an ICD)
• At least 40 days have passed since the most recent MI
• Optimization of medical therapy
• Expected survival with a good functional status of at least one year
• Among such patients:
• There is evidence and/or general agreement that ICD therapy is
appropriate for those with an LVEF <35 percent and NYHA class II or III HF
.
• There is evidence and/or general agreement that ICD therapy is
appropriate for those with an LVEF ≤30 percent and NYHA class I HF.
• Although the LVEF cutoffs in the first recommendation is <35 percent, the
clinical trials upon which this recommendations is based (SCD-HeFT)
included patients with LVEFs ≤35 percent . We recommend adherence to
the clinical trial criteria and using the cutoff of LVEF ≤35 percent
•  According to CMS, assessment of LV function and/or severity of HF
for the purpose of assessing the need for an ICD should be done at
least three months after the most recent revascularization procedure
(either percutaneous or surgical). Although the
2008 ACC/AHA/HRS guidelines do recommend delaying ICD
implantation for 40 days after an acute MI, they do not require
waiting three months after revascularization.
• Cardiac resynchronization  — The COMPANION trial demonstrated the benefit of a device with both ICD and
CRT capabilities in patients with NYHA class III-IV HF , an LVEF ≤35 percent, and evidence of LV dyssynchrony.
These results affect patients with NYHA class IV HF who were excluded from SCD-HeFT.
• The 2008 ACC/AHA/HRS guidelines suggest that there is evidence and/or general agreement that CRT, with
or without ICD therapy, is appropriate in patients meeting all of the following criteria [ 35 ]:
• NYHA class III or ambulatory class IV heart failure
• Optimization of medical therapy
• Sinus rhythm
• QRS complex of at least 120 msec in duration
• Expected survival with a good functional status of at least one year
The guidelines also stated that the weight of evidence and opinion is in favor of CRT in patients who meet the
above criteria with the following exceptions:
• Atrial fibrillation rather than sinus rhythm
• QRS less than 120 msec in duration, but frequent dependence on ventricular pacing
• Center for Medicare Services  — Based upon the results of MADIT II, SCD-HeFT,
DINAMIT, and COMPANION, the CMS expanded the indications for ICD insertion
in January 2005 . The indications include:
• Documented prior MI, LVEF ≤35 percent, and inducible sustained VT or VF on EP
study; the MI must have occurred more than four weeks previously and the EP
study must be performed more than four weeks after the MI (MADIT I criteria).
• Documented prior MI and LVEF ≤30 percent (MADIT II criteria).
• Ischemic dilated cardiomyopathy, documented prior MI, NYHA class II or III HF ,
and LVEF ≤35 percent (SCD-HeFT criteria).
• Patients who meet all current CMS coverage requirements for a CRT device and
have NYHA class IV HF (COMPANION criteria)
Exclusions include:
• Prior MI within the past 40 days (DINAMIT criteria)
• Hypotension or cardiogenic shock while in a stable baseline rhythm
• CABG or PCI within the past three months
• Symptoms or findings that would make the patient a candidate for
revascularization
• Noncardiac disease associated with expected survival or less than one
year or irreversible brain damage