Preventing Sudden Cardiac Death: Can We Afford the Benefit?

Editorials19 April 2005Preventing Sudden Cardiac Death: Can We Afford the Benefit?Stephen G. Pauker, MD, N. A. Mark Estes, MD, and Deeb N. Salem, MDStephen G. Pauker, MDFrom Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111., N. A. Mark Estes, MDFrom Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111., and Deeb N. Salem, MDFrom Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-142-8-200504190-00015 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Over the past 2 decades, we have made progress toward the Holy Grail of preventing sudden cardiac death. The implantable cardioverter defibrillator (ICD) is an effective but expensive therapy for primary and secondary prevention of this disorder (1, 2). Because health care resources are limited, when therapies are both effective and expensive, one must consider whether the benefits are worth the expense. A cost-effectiveness analysis answers that question by calculating the ratio of incremental cost to incremental effectiveness. Comparisons to other therapies are then possible. The lower the incremental cost-effectiveness ratio, the better the use of resources and the more ...References1. Ezekowitz JA, Armstrong PW, McAlister FA. Implantable cardioverter defibrillators in primary and secondary prevention: a systematic review of randomized, controlled trials. Ann Intern Med. 2003;138:445-52. [PMID: 12639076] LinkGoogle Scholar2. Nanthakumar K, Epstein AE, Kay GN, Plumb VJ, Lee DS. Prophylactic implantable cardioverter-defibrillator therapy in patients with left ventricular systolic dysfunction: a pooled analysis of 10 primary prevention trials. J Am Coll Cardiol. 2004;44:2166-72. [PMID: 15582314] CrossrefMedlineGoogle Scholar3. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877-83. [PMID: 11907286] CrossrefMedlineGoogle Scholar4. Al-Khatib SM, Anstrom KJ, Eisenstein EL, Peterson ED, Jollis JG, Mark DB, et al. Clinical and economic implications of the Multicenter Automatic Defibrillator Implantation Trial-II. Ann Intern Med. 2005;142:593-600. LinkGoogle Scholar5. Fortin DF, Califf RM, Pryor DB, Mark DB. The way of the future redux [Editorial]. Am J Cardiol. 1995;76:1177-82. [PMID: 7484906] CrossrefMedlineGoogle Scholar6. Hlatky MA. Evidence-based use of cardiac procedures and devices. N Engl J Med. 2004;350:2126-8. [PMID: 15152058] CrossrefMedlineGoogle Scholar7. Hlatky MA, Bigger T. Cost-effectiveness of the implantable cardioverter defibrillator? Lancet. 2001;357:1817-8. [PMID: 11410185] CrossrefMedlineGoogle Scholar8. Essebag V, Eisenberg MJ. Expanding indications for defibrillators after myocardial infarction: risk stratification and cost effectiveness. Card Electrophysiol Rev. 2003;7:43-8. [PMID: 12766517] CrossrefMedlineGoogle Scholar9. Owens DK, Sanders GD, Heidenreich PA, McDonald KM, Hlatky MA. Effect of risk stratification on cost-effectiveness of the implantable cardioverter defibrillator. Am Heart J. 2002;144:440-8. [PMID: 12228780] CrossrefMedlineGoogle Scholar10. Weiss JP, Saynina O, McDonald KM, McClellan MB, Hlatky MA. Effectiveness and cost-effectiveness of implantable cardioverter defibrillators in the treatment of ventricular arrhythmias among medicare beneficiaries. Am J Med. 2002;112:519-27. [PMID: 12015242] CrossrefMedlineGoogle Scholar11. Sheldon R, O'Brien BJ, Blackhouse G, Goeree R, Mitchell B, Klein G, et al. Effect of clinical risk stratification on cost-effectiveness of the implantable cardioverter-defibrillator: the Canadian implantable defibrillator study. Circulation. 2001;104:1622-6. [PMID: 11581139] CrossrefMedlineGoogle Scholar12. Sanders GD, Hlatky MA, Every NR, McDonald KM, Heidenreich PA, Parsons LS, et al. Potential cost-effectiveness of prophylactic use of the implantable cardioverter defibrillator or amiodarone after myocardial infarction. Ann Intern Med. 2001;135:870-83. [PMID: 11712877] LinkGoogle Scholar13. Hohnloser SH, Kuck KH, Dorian P, Roberts RS, Hampton JR, Hatala R, et al. Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med. 2004;351:2481-8. [PMID: 15590950] CrossrefMedlineGoogle Scholar14. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225-37. [PMID: 15659722] CrossrefMedlineGoogle Scholar15. Sondhi M, Goffin JR, Cohen BJ, Wong JB, Pauker SG. DEALE-ing with lung cancer and heart failure. Med Decis Making. 2005;25:82-94. [PMID: 15673585] CrossrefMedlineGoogle Scholar16. Bradley DJ, Bradley EA, Baughman KL, Berger RD, Calkins H, Goodman SN, et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized, controlled trials. JAMA. 2003;289:730-40. [PMID: 12585952] CrossrefMedlineGoogle Scholar17. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140-50. [PMID: 15152059] CrossrefMedlineGoogle Scholar18. Jauhar S, Slotwiner DJ. The Economics of ICDs [Editorial]. N Engl J Med. 2004;351:2542-4. [PMID: 15590958] CrossrefMedlineGoogle Scholar19. McClellan MB, Tunis SR. Medicare coverage of ICDs. N Engl J Med. 2005;352:222-4. [PMID: 15659721] CrossrefMedlineGoogle Scholar20. Centers for Medicare and Medicaid Services. Draft Decision Memo for Implantable Defibrillators (CAG-00157R2). 2004. Accessed at www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?id=139 on 5 February 2005. Google Scholar Author, Article, and Disclosure InformationAffiliations: From Tufts-New England Medical Center and Tufts University School of Medicine; Boston, MA 02111.Disclosures: Dr. Estes was the principal investigator of MADIT-II at the Tufts-New England Medical Center and is on the MADIT-CRT [Cardiac Resynchronization Therapy] Executive Committee. Both trials are ICD trials funded by Guidant Corporation.Corresponding Author: Stephen G. Pauker, MD, Tufts-New England Medical Center, Box 302, 750 Washington Street, Boston, MA 02111; e-mail, [email protected]org.Current Author Addresses: Drs. Pauker, Estes, and Salem: Tufts-New England Medical Center, Box 302, 750 Washington Street, Boston, MA 02111. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoClinical and Economic Implications of the Multicenter Automatic Defibrillator Implantation Trial-II Sana M. Al-Khatib , Kevin J. Anstrom , Eric L. Eisenstein , Eric D. Peterson , James G. Jollis , Daniel B. Mark , Yun Li , Christopher M. O'Connor , Linda K. Shaw , and Robert M. Califf Preventing Sudden Cardiac Death Michael Achtelik Preventing Sudden Cardiac Death Stephen G. Pauker , N. A. Mark Estes , and Deeb N. Salem Metrics Cited ByRecent temporal trends in hospital costs for non-surgical patients receiving implantable cardioverter defibrillatorsWarning Symptoms Are Associated With Survival From Sudden Cardiac ArrestEloi Marijon, MD, PhD, Audrey Uy-Evanado, MD, Florence Dumas, MD, PhD, Nicole Karam, MD, MPH, Kyndaron Reinier, MPH, PhD, Carmen Teodorescu, MD, PhD, Kumar Narayanan, MD, Karen Gunson, MD, Jonathan Jui, MD, Xavier Jouven, MD, PhD, and Sumeet S. Chugh, MDVariation among hospitals in selection of higher-cost, "higher-tech," implantable cardioverter-defibrillators: Data from the National Cardiovascular Data Registry (NCDR) Implantable Cardioverter/Defibrillator (ICD) RegistryJust Caring: Defining a Basic Benefit PackageDevices for Heart Failure: The Future Is NowInequitable distribution of implantable cardioverter defibrillators in OntarioPrimary Prevention of Sudden Cardiac Death: Can We Afford the Cost of Cardioverter-Defibrillators? Data from the Search-MI Registry-Italian Sub-studyThe Frequency and Incremental Cost of Major Complications Among Medicare Beneficiaries Receiving Implantable Cardioverter-DefibrillatorsProportion of Patients Followed in a Specialized Heart Failure Clinic Needing an Implantable Cardioverter Defibrillator as Determined by Applying Different Trial Eligibility CriteriaEnd‐of‐Life and Other Ethical Issues Related to Pacemaker and Defibrillator Use in the ElderlyViewpoint from Israel, February 7, 2006Preventing Sudden Cardiac DeathMichael Achtelik, MDWho Needs a Defibrillator?Primary Prevention of Sudden Cardiac Death: A Rational Approach to the Use of the Implantable Cardioverter Defibrillator 19 April 2005Volume 142, Issue 8Page: 664-666KeywordsDatabasesDeath ratesEjection fractionHeart failureLife expectancyPatientsQuality of lifeSudden cardiac death ePublished: 19 April 2005 Issue Published: 19 April 2005 CopyrightCopyright © 2005 by American College of Physicians. 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