Miloš Táborský, Petr Heinc, Vlastimil Doupal, Marián Fedorco, Ingrid Sovová, Albert Louis
The recommendations of the European Society of Cardiology and the american cardiologic societies for the provision of implantable cardioverter-defibrillators were formulated based on the interpretation of results collected from large randomised clinical trials for secondary and primary prevention of sudden cardiac death that were conducted about 10 to 20 years ago. However, in the years thereafter there have been significant changes in the standards for interventional therapy of acute myocardial infarction and various advancements made in its pharmacotherapy. As a result there are variations in the character of ventricular arrhythmias that patients present with. Furthermore, the use of the left ventricular ejection fraction as a factor to stratify the risk of developing sudden cardiac death is not optimal as it has a relatively low sensitivity and specificity on its own. There has not yet been a clear establishment of more robust predictors of sudden cardiac death which in combination with the left ventricular ejection fraction could be used to seek out high-risk patients more efficiently. Moreover at the present time the long-term benefits of ICD therapy in older patients and women are not really clear. On the contrary, it appears that the QRS complex prolongation is a significant independent risk factor for all-cause mortality in patients with heart failure and independent of the ejection fraction of the left ventricle. This marker has a perspective to be applied as an additional independent risk factor of total mortality and sudden cardiac death in order to optimize the ICD indication criteria. And last but not least the economic factor is to be mentioned, which even in advanced economies does not permit the implantation of ICDs in all patients according to current applicable guidelines. We believe that it is necessary to reconsider the existing indications for ICD implantation both in light of the new findings made in the medical field and also taking into consideration the economic capabilities of the European health care systems.