SCD-HeFT: Heart patient guidelines for ICDs updated.

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2005 Guidelines

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

ACC/AHA/NASPE 2002 Updated Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

View Pocket Guidelines- PDF from ACC

Heart Failure Guideline Recommendations for Device Therapy22

Class I Recommendations for ICD Therapy

  1. An implantable cardioverter-defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. (Level of Evidence: A)
  2. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with ischemic heart disease who are at least 40 days post-MI, have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A)
  3. Implantable cardioverter-defibrillator therapy is recommended for primary prevention to reduce total mortality by a reduction in sudden cardiac death in patients with nonischemic cardiomyopathy who have an LVEF less than or equal to 30%, with NYHA functional class II or III symptoms while undergoing chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: B)

Class IIa Recommendations for ICD Therapy

  1. Placement of an implantable cardioverter-defibrillator is reasonable in patients with LVEF of 30% to 35% of any origin with NYHA functional class II or III symptoms who are taking chronic optimal medical therapy and who have reasonable expectation of survival with good functional status of more than 1 year. (Level of Evidence: B)
  2. Placement of an ICD is reasonable in patients with ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are NYHA functional class I on chronic optimal medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: B)

Class IIb Recommendation for ICD Therapy
Placement of an ICD might be considered in patients without HF who have nonischemic cardiomyopathy and an LVEF less than or equal to 30% who are in NYHA functional class I with chronic optimal medical therapy and have a reasonable expectation of survival with good functional status for more than 1 year. (Level of Evidence: C)

Class I Recommendation for CRT Therapy
Patients with LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dyssynchrony, which is currently defined as a QRS duration greater than 120 ms, should receive cardiac  resynchronization therapy unless contraindicated. (Level of Evidence: A)

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

Level of Evidence

Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.

Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.

Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care.

View and print The New England Journal of Medicine article online


WHAT'S NEW

New ACC/AHA Heart Failure Pocket Guidelines

SCD-HeFT Overview Presentation (Oct 05)

ACC/AHA NASPE 2002 Updated Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices24

View Full Guidelines - PDF from ACC

View Summary Article - PDF from ACC

Level of Evidence Classification:

Level A: Data derived from multiple randomized clinical trials involving a large number of individuals

Level B: Data derived from a limited number of trials involving comparatively small numbers of patients or from well-designed data analysis of nonrandomized studies or observational data registries

Level C: Consensus of expert opinion was the primary source of recommendation

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb: Usefulness/efficacy is less well established by evidence/opinion

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful

Class I Indications for ICD Therapy

  1. Cardiac arrest due to VF or VT not due to a transient or reversible cause (Level of Evidence: A)
  2. Spontaneous sustained VT in association with structural heart disease (Level of Evidence: B)
  3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at EP study when drug therapy is ineffective, not tolerated, or not preferred (Level of Evidence: B)
    • Nonsustained VT in patients with coronary disease, prior MI, LV dysfunction, and inducible VF or sustained VT at EP study that is not suppressible by a Class I antiarrhythmic drug (Level of Evidence: A)
    • Spontaneous sustained VT in patients without structural heart disease not amenable to other treatments (Level of Evidence: C)

Class IIa Indications for ICD

Patients with left ventricular ejection fraction of less than or equal to 30% at least 1 month post myocardial infarction and 3 months post coronary artery revascularization surgery (Level of Evidence: B)

Class IIb Indications for ICD

  1. Cardiac arrest presumed to be due to VF when EP testing is precluded by other medical conditions (Level of Evidence: C)
  2. Severe symptoms (e.g. syncope) attributable to sustained ventricular tachyarrhythmias while awaiting cardiac transplantation (Level of Evidence: C)
  3. Familial or inherited conditions with a high risk for life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy (Level of Evidence: B)
    • Nonsustained VT with coronary artery disease, prior MI, and LV dysfunction, and inducible sustained VT or VF at EP study (Level of Evidence: B)
    • Recurrent syncope of undetermined etiology in the presence of ventricular dysfunction and inducible ventricular arrhythmias at EP study, when other causes of syncope have been excluded (Level of Evidence: C)

Class III Indications for ICD Therapy

  • Syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease (Level of Evidence: C)
  • Incessant VT or VF (Level of Evidence: C)
  • VF or VT resulting from arrhythmias amenable to surgical or catheter ablation; for example atrial arrhythmias associated with Wolfe-Parkinson-White syndrome, right ventricular outflow tract VT, idiopathic left ventricular tachycardia, or fascicular VT (Level of Evidence: C)
  • Ventricular tachyarrhythmias due to a transient or reversible disorder (e.g. AMI, electrolyte imbalance, drugs, or trauma) when correction of the disorder is considered feasible and likely to substantially reduce the risk of recurrent arrhythmia (Level of Evidence: C)
  • Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up (Level of Evidence: C)
  • Terminal illnesses with projected life expectancy less than 6 months (Level of Evidence: C)
  • Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the absence of spontaneous or inducible sustained or nonsustained VT who are undergoing coronary bypass surgery (Level of Evidence: B)
  • NYHA Class IV drug-refractory congestive heart failure in patients who are not candidates for cardiac transplantation (Level of Evidence: C)

22ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult (www.acc.org and www.americanheart.org). Copyright 2005 The American College of Cardiology Foundation and American Heart Association, Inc. Permission granted for limited use. Further reproduction is not permitted without permission of the ACC/AHA.

24Gregoratos G. et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article. Circulation. 2002;106:2145-2161