100 QUESTIONS IN CARDIOLOGY

33 Familial or inherited conditions with a high risk for life-

threatening ventricular tachyarrhythmia such as long QT

syndrome or hypertrophic cardiomyopathy.

44 Non-sustained VT with coronary artery disease, prior MI, and

LV dysfunction, and inducible sustained VT or VF at electro-

physiological study.

55 Recurrent syncope of undetermined aetiology in the presence

of ventricular dysfunction and inducible ventricular

arrhythmias at electrophysiological study when other causes of

syncope have been excluded.

The size of the risk reduction to patients and the degree of life

prolongation are only moderate in the trials showing benefit of

ICD over antiarrhythmic therapy. The cost per life year saved is

also wildly different in these trials giving us conflicting

information, e.g. $22,800 (MADIT) and $114,917 (AVID).

There is a wide variation in implant rates across the world

(Table 87.1).

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USA 23,407 34,121 120
Germany 1975 3556 45
France 210 420 10
Italy 280 950 16
Netherlands 150 220 9
UK 240 410 7

The UK has one of the lowest implant rates in Western Europe

and it is not clear if this is reflective of a conservative approach by

UK cardiologists, tight budgetary constraints or a lack of clear

clinical trial data. The recently published NICE guidelines, if

implemented, will result in an increase in the ICD implantation

rate to 50 per million.^2

In conclusion, a patient who has survived an out of hospital

cardiac arrest unrelated to a transient or reversible cause should

receive a device irrespective of inducibility at EP study. If this

patient has an EF < 35% the case for this is stronger. Patients who

have repeated hospital admissions for symptomatic sustained

ventricular tachycardia that are not amenable to RF ablation are

also clear beneficiaries as well as providing a long term cost saving