Primary prevention implantable cardioverter defibrillators in non‐ischaemic cardiomyopathy: challenging the Australian heart failure guidelines

Dennis H Lau, Jonathan M Kalman and Prashanthan Sanders
Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50248
Published online: 19 August 2019

The 2018 Australian guidelines recommendations require further clarification to ensure eligible patients will receive appropriate ICD therapy

The implantable cardioverter defibrillator (ICD) has been shown to be a cost‐effective option for primary prevention of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). However, in the recently published 2018 guidelines for the prevention, detection and management of heart failure in Australia, the National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Heart Failure Guidelines Working Group downgraded the recommendation for primary prevention ICD to decrease mortality in patients with HFrEF and left ventricular ejection fraction (LVEF) 35% or below associated with non‐ischaemic cardiomyopathy (NICM).1,2 In particular, the level of recommendation and quality of evidence for primary prevention ICD was deemed weak and low for NICM versus strong and moderate for ischaemic cardiomyopathy, respectively. The document cited the lack of single randomised controlled trials demonstrating mortality benefits with primary prevention ICD in patients with NICM. It also highlighted recent prospective randomised controlled data of 1116 patients with HFrEF and LVEF 35% or below associated with non‐ischaemic causes from the DANISH trial — a Danish study to assess the efficacy of ICD in patients with non‐ischaemic systolic heart failure on mortality — whereby primary prevention ICD did not reduce mortality compared with usual clinical care over a median follow‐up duration of 67.6 months (interquartile range, 49–85 months).3

  • Dennis H Lau1,2
  • Jonathan M Kalman3,4
  • Prashanthan Sanders1,2

  • 1 Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, SA
  • 2 Royal Adelaide Hospital, Adelaide, SA
  • 3 University of Melbourne, Melbourne, VIC
  • 4 Royal Melbourne Hospital, Melbourne, VIC


Dennis Lau is supported by the Robert J Craig Lectureship from the University of Adelaide. Jonathan Kalman and Prashanthan Sanders are supported by Practitioner Fellowships from the National Health and Medical Research Council. Prashanthan Sanders is supported by the National Heart Foundation of Australia.

Competing interests:

The University of Adelaide reports receiving on behalf of Dennis Lau lecture and/or consulting fees from Abbott, Bayer, Biotronik and Pfizer. Prashanthan Sanders reports having served on the advisory board of Biosense‐Webster, Medtronic, Abbott, Boston Scientific and CathRx. The University of Adelaide reports receiving on behalf of Prashanthan Sanders lecture and/or consulting fees from Biosense‐Webster, Medtronic, Abbott, and Boston Scientific. The University of Adelaide reports receiving on behalf of Prashanthan Sanders research funding from Medtronic, Abbott, Boston Scientific, Biotronik and Liva Nova.


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