ICD indications

An overview of ICD and CRT(D) indications as recommended by the European Society of Cardiology. For all indications patient should be on optimal medical therapy and have a life expectancy of > 1 year.

Class I (recommendations)

• Patients with left ventricular dysfunction due to prior myocardial infarction who are at least 40 days post MI with LVEF <30-40%, are NYHA class II or III and are receiving chronic optimal medical therapy and with life expectancy > 1 year. IA[1]
• LV dysfunction due to prior MI, presenting with hemodynamically unstable sustained VT. IA[1][2]
• Patients with non-ischemic dilated cardiomyopathy (NI DCM) with LV dysfunction who have sustained VT or VF. IA[1]
• NI DCM LVEF<30-35%. NYHA II-III. Chronic medical therapy. Life expectancy > 1 year. IB[1]
• Hypertrophic cardiomyopathy with sustained VT or VF. IB[1]
• Arrhythmogenic right ventricular cardiomyopathy with documented sustained VT or VF. OMT, LE>1y.IB [1]
• Sustained VT, hemodynamically unstable VT, VT with syncopy, or VF. LVEF< 40%. IA[1]
• LQTS with previous cardiac arrest. IA[1]
• Brugada syndrome with previous cardiac arrest. IC[1]
• CPVT with previous cardiac arrest. IC[1]
• An ICD is recommended in a patient with heart failure with a ventricular arrhythmia causing haemodynamic instability. LE>1y. IA [2]
• CRTD is recommended in patients with sinus rhythm, LBBB, QRS > 130ms, EF<30%, NYHA II. IA [2][3]
• CRTD is recommended in patients with sinus rhythm, LBBB, QRS > 120ms, EF<35%, NYHA III-IV. IA [2][3]
• CRT in patient with an other Class I pacemaker indication who is in NYHA III/IV, LVEF ≤35%, QRS ≥120 ms. IB[4]
• Syncope, documented VT and structural heart disease. IB [4]
• When monomorphic VT is induced at EP study in patients with previous myocardial infarction and syncope. IB [4]

Class IIa (should be considered)

• LV dysfunction due to prior MI, at least 40 days post MI, LVEF < 30-35%, NYHA I, on chronic medical therapy, life expectancy >1y. IIaB[1]
• Recurrent VT in post MI patient with normal or near normal LVEF on chronic medical therapy, life expectancy > 1y. IIaC[1]
• In patients with life threatening arrhythmias who are not in the acute phase of myocarditis, on chronic medical therapy, life expectancy >1y. IIaC[1]
• Unexplained syncope, significant LV dysfunction, non-ischemic DCM. Optimal medical therapy, LE>1y. IIaC[1]
• Sustained VT with (near) normal LV function and non-ischemic DCM. Optimal medical therapy, LE>1y. IIaC[1]
• HCM with high risk (>5% in 5y): http://doc2do.com/hcm/webHCM.html [5]
• Arrhythmogenic right ventricular cardiomyopathy with extensive disease, including those with LV dysfunction 1 or more affected family members with SCD, or undiagnosed syncope when VT or VF has not been excluded as the cause of syncope. OMT, LE>1y.IB [1]
• CRTD, NYHA III/IV, SR, QRS>120ms. IIaB. [1]
• LQTS with syncope and / or VT while on beta blockers. [1]
• Brugada syndrome with spontaneous type I ECG and who have had syncope. [1]
• Brugada syndrome with documented VT that has not resulted in cardiac arrest. [1]
• A CRTD should be considered in a patient with non-LBBB, QRS > 150ms, EF<35%, NYHA III-IV . IIaA[2]
• A CRTD should be considered in a patient with non-LBBB, QRS > 150ms, EF<30%, NYHA II . IIaA[2][3][3]
• A CRTD/CRTP may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who is pacemaker dependant, after AV nodal ablation QRS > 130ms, EF<35%, NYHA III-IV . IIaA[2][3]
• CRT may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who requires pacing because of intrinsically slow ventricular rate with QRS > 130ms, EF<35%, NYHA III-IV . IIaC[2][3]
• In patients with documented VT with inherited cardiomyopathies or channelopathies. IIaB. [4]
• CRT in patient with an other Class I pacemaker indication who is in NYHA III/IV, LVEF ≤35%, QRS <120 ms. IIaC[4]

Class IIb (may be considered)

• nonischemic DCM, LVEF < 30-35%, NYHA I. optimal medical therapy, LE>1y. IIbC[1]
• CRT may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who requires pacing because of a rate of < 60 bpm in rest and < 90 bpm on exercise with QRS > 120ms, EF<35%, NYHA III-IV . IIbC[2]
• CRT should be considered in those patient with atrial fibrillation in NYHA functional class II with an EF ≤35%, irrespective of QRS duration, to reduce the risk of worsening of HF. IIbC[2]
• CRT in patient with an other Class I pacemaker indication who is in NYHA II, LVEF ≤35%, QRS <120 ms. IIbC[4]

Class III (not recommended)

• ICD implantation is not recommended during the acute phase of myocarditis[1]

References

1. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL, Smith SC Jr, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, American College of Cardiology, American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines, European Heart Rhythm Association, and Heart Rhythm Society. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace. 2006 Sep;8(9):746-837. DOI:10.1093/europace/eul108 |
2. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K, Falk V, Filippatos G, Fonseca C, Gomez-Sanchez MA, Jaarsma T, Køber L, Lip GY, Maggioni AP, Parkhomenko A, Pieske BM, Popescu BA, Rønnevik PK, Rutten FH, Schwitter J, Seferovic P, Stepinska J, Trindade PT, Voors AA, Zannad F, Zeiher A, Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology, Bax JJ, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, McDonagh T, Sechtem U, Bonet LA, Avraamides P, Ben Lamin HA, Brignole M, Coca A, Cowburn P, Dargie H, Elliott P, Flachskampf FA, Guida GF, Hardman S, Iung B, Merkely B, Mueller C, Nanas JN, Nielsen OW, Orn S, Parissis JT, Ponikowski P, and ESC Committee for Practice Guidelines. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2012 Aug;14(8):803-69. DOI:10.1093/eurjhf/hfs105 |
3. Dickstein K, Vardas PE, Auricchio A, Daubert JC, Linde C, McMurray J, Ponikowski P, Priori SG, Sutton R, van Veldhuisen DJ, and ESC Committee for Practice Guidelines (CPG). 2010 Focused Update of ESC Guidelines on device therapy in heart failure: an update of the 2008 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy. Developed with the special contribution of the Heart Failure Association and the European Heart Rhythm Association. Eur Heart J. 2010 Nov;31(21):2677-87. DOI:10.1093/eurheartj/ehq337 |
4. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, and Wieling W. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009 Nov;30(21):2631-71. DOI:10.1093/eurheartj/ehp298 |
5. Authors/Task Force members, Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, and Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014 Oct 14;35(39):2733-79. DOI:10.1093/eurheartj/ehu284 |