Cost-Effectiveness of ICD Therapy in the Prevention of Sudden Death in CAD and/or HF Patients

  • Andrea Pozzolini
Conference paper


Sudden cardiac death (SCD) is one of the most common causes of death in Western countries [1, 2], and its prevention poses a major challenge to both policymakers and health-care providers. The fundamental principle of evidence-based medicine is that clinical practice should rest on a sound scientific foundation established by clinical studies involving human subjects. The strategies of primary and secondary prevention of SCD with the implantable cardioverter defibrillator (ICD) have received increased attention in the last few years, mainly because multiple prospective randomized clinical trials (RCT) [3, 4] have yielded concordant and consistent results showing that ICD therapy is highly effective in reducing SCD and all-cause mortality in selected patients with impaired left ventricular function on optimized medical treatment (OMT), including post-MI patients as well as patients with nonischemic cardiomyopathy. It is now known that in such patients ICDs reduce mortality by approximately one-third over and above OMT [3]–[8]. Faced with this evidence, recently updated practice guidelines [9]–[11] have suggested a broadening of the indications for prophylactic ICD use; but opinions diverge on the desirability for expansion of this expensive therapeutic strategy, whose widespread implementation threatens to impact heavily on public health-care spending. Thus nowadays, due to the high cost of ICDs and the large population of patients potentially eligible to receive them, the debate on ICDs has moved from issues of feasibility and effectiveness to questions about costs and cost-effectiveness.


Sudden Cardiac Death Cardiac Resynchronization Therapy Implantable Cardioverter Defibrillator Therapy Implantable Cardioverter Defibrillator Implantation Multicenter Automatic Defibrillator Implantation Trial 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Zheng ZJ, Croft JB, Giles WH et al (2001) Sudden cardiac death in the United States, 1989 to 1998. Circulation 104:2158–2163PubMedCrossRefGoogle Scholar
  2. 2.
    Josephson M, Wellens HJ (2004) Implantable defibrillators and sudden cardiac death. Circulation 109:2685–2691PubMedCrossRefGoogle Scholar
  3. 3.
    Nanthakumar K, Epstein A, Kay GN et al (2004) Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction: a pooled analysis of 10 primary prevention trials. J Am Coll Cardiol 44:2166–2172PubMedCrossRefGoogle Scholar
  4. 4.
    Desai A, Fang J, Maisel W et al (2004) Implantable defibrillators for the prevention of mortality in patients with nonischemic cardiomyopathy: a meta-analysis of randomized controlled trials. JAMA 292:2874–2879PubMedCrossRefGoogle Scholar
  5. 5.
    Moss AJ, Zareba W, Hall WJ (2002) Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 346:877–883PubMedCrossRefGoogle Scholar
  6. 6.
    The Antiarrhythmic Versus Implantable Defibrillator (AVID) Investigators (1997) A comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med 337:1576–1583CrossRefGoogle Scholar
  7. 7.
    Bristow M, Saxon L, Boehmer J et al (2004) Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 350:2140–2150PubMedCrossRefGoogle Scholar
  8. 8.
    Bardy GH, Lee KL, Mark DB et al (2005) Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 352:225–23PubMedCrossRefGoogle Scholar
  9. 9.
    Hunt SA, Abraham WT, Chin MH et al (2005) ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 46:e1–e82PubMedCrossRefGoogle Scholar
  10. 10.
    Zipes DP, Camm AJ, Borggrefe M et al (2006) ACC/AHA/ESC 2006 Guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death — executive summary. J Am Coll Cardiol 48:1064–1108CrossRefGoogle Scholar
  11. 11.
    Lunati M et al (2005) Linee guida AIAC all’impianto di pacemaker, dispositivi per la resincronizzazione cardiaca (CRT) e defibrillatori automatici impiantabili (ICD). Giornale italiano di Aritmologia e Cardiostimolazione 8:1–58Google Scholar
  12. 12.
    Brown GC, Brown MM, Sharma S (2003) Value-based medicine: evidence-based medicine and beyond. Ocul Immunol Inflamm 11:157–170PubMedCrossRefGoogle Scholar
  13. 13.
    Boriani G, Biffi M, Martignani C et al (2003) Cardioverter-defibrillators after MADIT II: the balance between weight of evidence and treatment costs. Eur J Heart Failure 5:419–425CrossRefGoogle Scholar
  14. 14.
    Meltzer MI (2001) Introduction to health economics for physicians. Lancet 358:993–998PubMedCrossRefGoogle Scholar
  15. 15.
    Mark DB, Hlatky MA (2002) Medical economics and the assessment of value in cardiovascular medicine. Part I. Circulation 106:516–520PubMedCrossRefGoogle Scholar
  16. 16.
    Mark DB, Hlatky MA (2002) Medical economics and the assessment of value in cardiovascular medicine. Part II. Circulation 106:626–630PubMedCrossRefGoogle Scholar
  17. 17.
    Boriani G, Biffi M, Martignani C et al (2001) Cost-effectiveness of implantable cardioverter-defibrillators. Eur Heart J 22:990–996PubMedCrossRefGoogle Scholar
  18. 18.
    Boriani G, Larsen G (2006) Cost-effectiveness of implantable cardioverter-defibrillators. In: Priori S, Zipes DP (eds) Sudden cardiac death. Blackwell Publishing, Malden, pp 263–279Google Scholar
  19. 19.
    Stange PV, Sumner AT (1978) Predicting treatment costs and life expectancy for end-stage renal disease. N Engl J Med 298:372–378PubMedCrossRefGoogle Scholar
  20. 20.
    Spath MA, O’Brien BJ (2002) Cost-effectiveness of the implantable cardioverter defibrillator therapy versus drug therapy for patients at high risk of sudden cardiac death. Pharmacoeconomics 20:727–738PubMedCrossRefGoogle Scholar
  21. 21.
    Weinstein MC, Siegel JE, Gold MR et al (1996) Recommendations of the Panel on cost-effectiveness in health and medicine. JAMA 276:1253–1258PubMedCrossRefGoogle Scholar
  22. 22.
    Ezekowitz JA, Armstrong PW, McAlister FA (2003) Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomized, controlled trials. Ann Intern Med 138:445–452PubMedGoogle Scholar
  23. 23.
    Larsen G, Hallstrom A, McAnulty J et al (2002) Cost-effectiveness of the implantable cardioverter-defibrillator versus antiarrhythmic drugs in survivors of serious ventricular tachyarrhythmias: results of the Antiarrhythmic Versus Implantable Defibrillators (AVID) economic analysis substudy. Circulation 105:2049–2057PubMedCrossRefGoogle Scholar
  24. 24.
    Connolly SJ, Gent M, Roberts RS et al (2000) Canadian Implantable Defibrillator Study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation 101:1297–1302PubMedGoogle Scholar
  25. 25.
    O’Brien BJ, Connolly SJ, Goeree R et al (2001) Cost-effectiveness of the implantable cardioverter-defibrillator: results from the Canadian Implantable Defibrillator Study (CIDS). Circulation 103:1416–1421PubMedGoogle Scholar
  26. 26.
    Bokhari F, Newman D, Greene M et al (2004) Long term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS). Circulation 110:112–116PubMedCrossRefGoogle Scholar
  27. 27.
    Boriani G, Biffi M, Martignani C (2005) Letter regarding article by Bokhari et al “Long-term comparison of the implantable cardioverter defibrillator versus amiodarone: eleven-year follow-up of a subset of patients in the Canadian Implantable Defibrillator Study (CIDS)”. Circulation 111:e26PubMedCrossRefGoogle Scholar
  28. 28.
    Mushlin AI, Hall WJ, Zwanziger J et al (1998) The cost-effectiveness of automatic implantable cardiac defibrillators: results from MADIT. Multicenter Automatic Defibrillator Implantation Trial. Circulation 97:2129–2135PubMedGoogle Scholar
  29. 29.
    Centers for Medicare and Medicaid Services (2003) Decision memorandum: national coverage determination (NCD) on implantable defibrillators, pp 1–37Google Scholar
  30. 30.
    Al-Khatib SM, Anstrom KJ, Eisenstein EL et al (2005) Clinical and economic implications of the Multicenter Automatic Defibrillator Implantation Trial-II. Ann Intern Med 142:593–600PubMedGoogle Scholar
  31. 31.
    Zwanziger J, Hall WJ, Dick AW et al (2006) The cost-effectiveness of implantable cardioverter-defibrillators: results from the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II. J Am Coll Cardiol 47:2310–2318PubMedCrossRefGoogle Scholar
  32. 32.
    Feldman AM, de Lissovoy G, Bristow MR et al (2005) Cost effectiveness of cardiac resynchronization therapy in the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial. J Am Coll Cardiol 46:2311–2321PubMedCrossRefGoogle Scholar
  33. 33.
    Yao G, Freemantle N, Calvert MJ et al (2007) The long-term cost-effectiveness of cardiac resynchronization therapy with or without an implantable cardioverter-defibrillator. Eur Heart J 28:42–51PubMedCrossRefGoogle Scholar
  34. 34.
    Cleland JG, Daubert JC, Erdmann E et al (2005) The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 352:1539–1549PubMedCrossRefGoogle Scholar
  35. 35.
    Mark DB, Nelson CL, Anstrom KJ et al (2006) Cost-effectiveness of defibrillator therapy or amiodarone in chronic stable heart failure: results from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Circulation 114:135–142PubMedCrossRefGoogle Scholar
  36. 36.
    Sanders GD, Hlatky MA, Owens DK (2005) Cost-effectiveness of implantable cardioverter-defibrillators. N Engl J Med 353:1471–1480PubMedCrossRefGoogle Scholar
  37. 37.
    Hohnloser SH, Kuck KH, Dorian P et al (2004) Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med 351:2481–2488PubMedCrossRefGoogle Scholar
  38. 38.
    Bigger JT Jr (1997) Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery. N Engl J Med 337:1569–1575PubMedCrossRefGoogle Scholar
  39. 39.
    Buxton AE (2003) The clinical use of implantable cardioverter defibrillators: where are we now? Where should we go? Ann Int Med 138:512–514PubMedGoogle Scholar
  40. 40.
    Tavazzi L (2000) Ventricular pacing: a promising new therapeutic strategy in heart failure. For whom? Eur Heart J 21:1211–1214PubMedCrossRefGoogle Scholar
  41. 41.
    Boriani G (2006) From MADIT II to Search-MI Registry for primary prevention of sudden death in ischemic patients. Presented at the XII International Symposium on progress in clinical pacing, RomeGoogle Scholar
  42. 42.
    Boriani G, Biffi M, Russo M et al (2006) Primary prevention of sudden cardiac death: can we afford the cost of cardioverter-defibrillators? Data from the Search-MI Registry-Italian Sub-study. Pacing Clin Electrophysiol 29:S29–S34PubMedCrossRefGoogle Scholar
  43. 43.
    Owens DK, Sanders GD, Heidenreich PA et al (2002) Effect of risk stratification on cost-effectiveness of the implantable cardioverter-defibrillator. Am Heart J 144:440–448PubMedCrossRefGoogle Scholar
  44. 44.
    Gould PA, Krahn AD (2006) Complications associated with implantable cardioverter-defibrillator replacement in response to device advisories. JAMA 295:1907–1911PubMedCrossRefGoogle Scholar
  45. 45.
    Chan PS, Stein K, Chow T et al (2006) Cost-effectiveness of a microvolt T wave alternans screening strategy for implantable cardioverter-defibrillator placement in the MADIT II-eligible population. J Am Coll Cardiol 48:112–121PubMedCrossRefGoogle Scholar
  46. 46.
    Hlatky MA (2004) Evidence based use of cardiac procedures and devices. N Engl J Med 350:2126–2128PubMedCrossRefGoogle Scholar
  47. 47.
    Stevenson LW (2006) Implantable cardioverter-defibrillators for primary prevention of sudden death in heart failure. Are there enough bangs for the bucks? Circulation 114:101–103PubMedCrossRefGoogle Scholar
  48. 48.
    Sweeney MO, Schoenfeld MH, Cannom DS (2005) Rules of evidence: CMS and primary prevention of sudden cardiac death in systolic heart failure. Pacing Clin Electrophysiol 28:81–88PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2007

Authors and Affiliations

  • Andrea Pozzolini
    • 1
  1. 1.Cardiology Operative UnitSanta Croce HospitalFano (PU)Italy

Personalised recommendations