Prophylactic cardioverter defibrillator utilization in the "real world": a conundrum.

Randomized controlled trials have shown that implantable cardioverter defibrillator (ICD) therapy improves survival in appropriately selected patients with left ventricular dysfunction due to myocardial infarction (MI). Specific recommendations for ICD therapy have been included in consensus guidelines. There is, however, uncertainty as to whether guidelines on prophylactic ICD therapy are being applied in "real world" clinical practice. A report from a tertiary care center in Israel shows that in the period between 2005 and 2009, a prophylactic ICD was implanted in only 14% of post-MI patients in whom it was indicated, according to current guidelines. Importantly, failure to systematically reassess left ventricular function after a MI was linked to underuse of ICDs. Various factors such as differential coverage by health care insurances, patients' decision, physician's evaluation of co-morbidities and age, as well as under-referral to specialized centers may be involved in limiting the use of prophylactic ICDs. The shortfall in ICD implant rate in relation to that expected from current guidelines calls for further integration of healthcare systems.