From the Guidelines
An implantable cardioverter-defibrillator (ICD) is recommended for patients with an ejection fraction (EF) of 30% or less, regardless of New York Heart Association (NYHA) class, as long as they have an expected survival of at least 1 year. This recommendation is based on the latest guidelines from the American College of Cardiology/American Heart Association, as outlined in the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes 1. The guideline clearly states that patients with an LVEF of ≤30% are indicated for prophylactic ICD implantation for primary prevention in ischemic heart disease, as shown in Table 17 of the guideline.
Key considerations for ICD implantation in patients with an EF of 30% or less include:
- Expected survival of at least 1 year
- Presence of ischemic heart disease
- LVEF of ≤30%
- NYHA class I, II, or III heart failure symptoms are not a requirement for ICD implantation in patients with an LVEF of ≤30%
It is essential to note that the risk of ventricular arrhythmias and sudden cardiac death is highest early after myocardial infarction, but the routine implantation of a defibrillator for primary prevention in patients with LV dysfunction early after MI or CABG has not been associated with improved survival 1. However, ICD implantation is still recommended for patients with an EF of 30% or less, as it has been shown to reduce mortality by detecting and terminating life-threatening arrhythmias. Before ICD placement, patients should be on optimal medical therapy, including guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF).
From the Research
Implantable Cardioverter-Defibrillator (ICD) Indication
- An ICD is recommended for individuals with a history of cardiac arrest, ventricular fibrillation, or hemodynamically unstable ventricular tachycardia 2.
- For patients with ischemic heart disease, an ICD is indicated at least 40 days post-myocardial infarction, or for those with nonischemic cardiomyopathy, an LVEF of 30% or less, NYHA class II or III symptoms on optimal medical therapy, and an expectation of survival of at least 1 year 2.
Left Ventricular Ejection Fraction (LVEF) and ICD
- A patient with an LVEF of 30% or less may be considered for an ICD, provided they meet the other criteria outlined in the guidelines, such as NYHA class II or III symptoms and an expectation of survival of at least 1 year 2.
- The decision to implant an ICD should be based on a comprehensive evaluation of the patient's clinical status, including their LVEF, symptoms, and overall prognosis.
Additional Considerations
- Pharmacological therapy for heart failure with reduced ejection fraction, including angiotensin-converting enzyme inhibitors, beta-blockers, and mineralocorticoid receptor antagonists, should be optimized before considering an ICD 3, 4.
- Other treatments, such as cardiac resynchronization therapy, may also be considered for patients with heart failure and reduced ejection fraction, depending on their specific clinical characteristics 2.