Investigating Referrals for ICDs

The American College of Cardiology, American Heart Association, and Heart Rhythm Society have published guidelines that provide patient selection criteria for the use of implantable cardioverter-defibrillators (ICDs) as primary prevention. ICDs can be life-saving therapy for appropriate patients with cardiac abnormalities. Studies, however, suggest that guideline discordant practice is common. To further analyze this phenomenon, my colleagues and I conducted a study that was published in the February 2, 2012 issue of Heart Rhythm. We wanted to determine referring physicians’ concordance with the primary prevention ICD guidelines. Assessing Guideline Concordance & Discordance According to our findings, 28% of respondents never referred patients to specialists with the intent of considering them for a primary prevention ICD; 7% of such responses were seen in cardiologists. Many respondents didn’t understand left ventricular ejection fraction (LVEF) criteria or that ICDs can be indicated in the absence of ventricular arrhythmias. Guidelines-discordant responses were common overall: 15% reported that an ICD is never indicated in the absence of a ventricular arrhythmia. 6% reported that an LVEF greater than 40% can warrant a primary prevention ICD. 25% reported that they would refer a patient for a primary prevention ICD within 40 days of a myocardial infarction (MI). Family practitioners and physicians residing in the western part of the United States were most likely to provide guideline-discordant answers to the survey when compared with other respondents. General cardiologists and those who referred patients to electrophysiologists were more likely to answer survey questions in ways that were considered concordant with the guidelines. Discordant responses, however, were not unusual among general cardiologists; 4% reported that an ICD isn’t indicated...