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

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