Arq. Bras. Cardiol. 2025; 122(2): e20250142
Survival with ICD in Heart Failure: Truly Necessary or Just a Selection Bias?
This Short Editorial is referred by the Research article "Clinical Outcomes and Mortality in Patients with Implantable Cardioverter-Defibrillator for Primary Prevention".
Mortality predictors: The role of detailed clinical assessment
The importance of thorough medical consultations should be emphasized when evaluating these cases. Through anamnesis, potential mortality predictors can be identified, such as age, LVEF, BNP and/or NT-proBNP levels, coronary artery disease (CAD), diabetes mellitus, chronic kidney disease, baseline rhythm, HF-related hospitalizations, and NYHA >2 classification. The study by Başkurt et al. identified BNP > 508.5 pg/mL (ROC: S 69% and E 69%), LVEF < 24.5% (ROC: S 54% and E 63%), age > 68.5 years (ROC: S 62% and E 62%), and hospitalization due to decompensation as independent predictors of all-cause mortality, whereas CAD was not an independent risk factor., Similar findings were reported in a study by Bilchick et al., which analyzed a large cohort (n = 45,000), demonstrating that critically ill patients with multiple comorbidities have a higher risk of adverse outcomes.
Therefore, the need for a risk score has been discussed and validated over time, with examples including the MADIT-II ICD Risk Stratification Score and the Seattle Heart Failure Score. However, important differences exist between them: the presence of associated cardiac resynchronization therapy (not included in the Seattle model), differences in the definition of severe arrhythmia and arrhythmic death (MADIT-ICD Benefit Score uses potentially fatal arrhythmias as a marker of arrhythmic death, whereas other studies distinguish between sudden and non-sudden death), and updated validation with contemporary cohorts. The MADIT-ICD Benefit Score, proposed in 2021, aims to improve risk stratification by assisting individualized clinical decision-making through the identification of primary ICD implantation candidates with the highest survival benefit, those whose predicted VT/VF risk surpasses the competing risk of non-arrhythmic mortality.
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