ICD indications

An overview of ICD and CRT(D) indications as recommended by the European Society of Cardiology. For all indications patient should be on optimal medical therapy and have a life expectancy of > 1 year.

Class I (recommendations)

• Patients with left ventricular dysfunction due to prior myocardial infarction who are at least 40 days post MI with LVEF <30-40%, are NYHA class II or III and are receiving chronic optimal medical therapy and with life expectancy > 1 year. IAESCSCD
• LV dysfunction due to prior MI, presenting with hemodynamically unstable sustained VT. IAESCSCDESCHF
• Patients with non-ischemic dilated cardiomyopathy (NI DCM) with LV dysfunction who have sustained VT or VF. IAESCSCD
• NI DCM LVEF<30-35%. NYHA II-III. Chronic medical therapy. Life expectancy > 1 year. IBESCSCD
• Hypertrophic cardiomyopathy with sustained VT or VF. IBESCSCD
• Arrhythmogenic right ventricular cardiomyopathy with documented sustained VT or VF. OMT, LE>1y.IB ESCSCD
• Sustained VT, hemodynamically unstable VT, VT with syncopy, or VF. LVEF< 40%. IAESCSCD
• LQTS with previous cardiac arrest. IAESCSCD
• Brugada syndrome with previous cardiac arrest. ICESCSCD
• CPVT with previous cardiac arrest. ICESCSCD
• An ICD is recommended in a patient with heart failure with a ventricular arrhythmia causing haemodynamic instability. LE>1y. IA ESCHF
• CRTD is recommended in patients with sinus rhythm, LBBB, QRS > 130ms, EF<30%, NYHA II. IA ESCHFESCfocusedup
• CRTD is recommended in patients with sinus rhythm, LBBB, QRS > 120ms, EF<35%, NYHA III-IV. IA ESCHFESCfocusedup
• CRT in patient with an other Class I pacemaker indication who is in NYHA III/IV, LVEF ≤35%, QRS ≥120 ms. IBESCsyncope
• Syncope, documented VT and structural heart disease. IB ESCsyncope
• When monomorphic VT is induced at EP study in patients with previous myocardial infarction and syncope. IB ESCsyncope

Class IIa (should be considered)

• LV dysfunction due to prior MI, at least 40 days post MI, LVEF < 30-35%, NYHA I, on chronic medical therapy, life expectancy >1y. IIaBESCSCD
• Recurrent VT in post MI patient with normal or near normal LVEF on chronic medical therapy, life expectancy > 1y. IIaCESCSCD
• In patients with life threatening arrhythmias who are not in the acute phase of myocarditis, on chronic medical therapy, life expectancy >1y. IIaCESCSCD
• Unexplained syncope, significant LV dysfunction, non-ischemic DCM. Optimal medical therapy, LE>1y. IIaCESCSCD
• Sustained VT with (near) normal LV function and non-ischemic DCM. Optimal medical therapy, LE>1y. IIaCESCSCD
• HCM with high risk (>5% in 5y): http://doc2do.com/hcm/webHCM.html ESCHCM
• Arrhythmogenic right ventricular cardiomyopathy with extensive disease, including those with LV dysfunction 1 or more affected family members with SCD, or undiagnosed syncope when VT or VF has not been excluded as the cause of syncope. OMT, LE>1y.IB ESCSCD
• CRTD, NYHA III/IV, SR, QRS>120ms. IIaB. ESCSCD
• LQTS with syncope and / or VT while on beta blockers. ESCSCD
• Brugada syndrome with spontaneous type I ECG and who have had syncope. ESCSCD
• Brugada syndrome with documented VT that has not resulted in cardiac arrest. ESCSCD
• A CRTD should be considered in a patient with non-LBBB, QRS > 150ms, EF<35%, NYHA III-IV . IIaAESCHF
• A CRTD should be considered in a patient with non-LBBB, QRS > 150ms, EF<30%, NYHA II . IIaAESCHFESCfocusedupESCfocusedup
• A CRTD/CRTP may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who is pacemaker dependant, after AV nodal ablation QRS > 130ms, EF<35%, NYHA III-IV . IIaAESCHFESCfocusedup
• CRT may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who requires pacing because of intrinsically slow ventricular rate with QRS > 130ms, EF<35%, NYHA III-IV . IIaCESCHFESCfocusedup
• In patients with documented VT with inherited cardiomyopathies or channelopathies. IIaB. ESCsyncope
• CRT in patient with an other Class I pacemaker indication who is in NYHA III/IV, LVEF ≤35%, QRS <120 ms. IIaCESCsyncope

Class IIb (may be considered)

• nonischemic DCM, LVEF < 30-35%, NYHA I. optimal medical therapy, LE>1y. IIbCESCSCD
• CRT may be considered to reduce the risk of HF worsening in a patient with atrial fibrillation who requires pacing because of a rate of < 60 bpm in rest and < 90 bpm on exercise with QRS > 120ms, EF<35%, NYHA III-IV . IIbCESCHF
• CRT should be considered in those patient with atrial fibrillation in NYHA functional class II with an EF ≤35%, irrespective of QRS duration, to reduce the risk of worsening of HF. IIbCESCHF
• CRT in patient with an other Class I pacemaker indication who is in NYHA II, LVEF ≤35%, QRS <120 ms. IIbCESCsyncope

Class III (not recommended)

• ICD implantation is not recommended during the acute phase of myocarditisESCSCD

References

<biblio>

1. ESCSCD pmid=16935866
2. ESCHF pmid=22828712
3. ESCsyncope pmid=19713422
4. ESCfocusedup pmid=20801924
5. ESCHCM pmid=25173338

</biblio>