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Extending survival by reducing sudden death with implantable cardioverter‐defibrillators: a challenging clinical issue in non‐ischaemic and ischaemic cardiomyopathies

The story of the implantable cardioverter-defibrillator (ICD) as an effective tool for reducing sudden death and improving survival in appropriately selected patients has never been simple and since the pioneering era of Michel Mirowski1 has always been the subject of debate and controversy. In the last 15 years, randomized clinical trials and, as a consequence, evidence-based international guidelines have extended the clinical application of ICDs to increasingly broad patient populations, not only in the setting of secondary prevention of sudden cardiac death, but also in the setting of primary sudden cardiac death prevention (i.e. for patients who are identified as being at risk of life-threatening ventricular tachyarrhythmias, despite no previous history of these events).2,3 However, primary prevention is a particularly challenging area, as many years may pass before the benefits of the intervention can be perceived within the targeted population, and the financial burden of widespread implementation of such indications may constitute an important limitation in some economic settings.3,4 Recently, the results of the DANISH trial,5 focused on ICD implant for primary prevention in patients with non-ischaemic cardiomyopathy, appear to increase the uncertainty on the role of ICD for extending survival and stimulated a new debate on ICD benefit.