1. Sudden Cardiac Arrest: George Washington University Medical Center
Increasing Survival
Cynthia M. Tracy, M.D.
George Washington University Medical Center
Speaker has no relationships with any proprietary entity
producing health care goods or services consumed by or used on patients

2. Objectives
Upon completion of this activity, participants will be able to:
Describe current trends in cardiac vascular disease (CVD) and SCA.
Assess the risk of SCA in heart failure (HF) and post-myocardial infarction (MI) patients.
Describe 2008 ACC/AHA/HRS Class I guidelines for the use of implantable cardiac defibrillator (ICD) and cardiac resynchronization therapy with defibrillation (CRT-D) therapies in patients at risk of SCA, and the evidence supporting these guidelines.
Describe current utilization of device therapy and assess current use of these devices in your practice.

3. Agenda CVD Epidemiology and SCA Facts SCA Risk Factors
ICD and CRT-D Therapies
Secondary Prevention of SCA
Primary Prevention of SCA
Implications in Real-World Practice
Device Treatment Algorithms
Summary

4. CVD Epidemiology and SCA Facts

5. Prevalence of Cardiovascular Diseases in Adults
Age 20 and Older by Age and Sex
NHANES: .

6. Deaths from Cardiovascular Disease United States: 1900-2004

7. Percentage Breakdown of Deaths from Cardiovascular Diseases United States: 2004 (Final)
About 50% of CHD deaths are due to SCA. This is the largest cause of CV death.

8. Underlying Arrhythmias of SCA
Polymorphic VT 13%
Bradycardia 17%
Monomorphic VT 62%
Primary VF 8%
Bayés de Luna A, et al. Am Heart J. 1989;117:

9. Magnitude of Deaths from SCA in the United States
* Range: 166,200 to 310,000
1 Vital Statistics of the U.S., Data Warehouse, National Center for Health Statistics Department of Health and Human Services. Centers for Disease Control and Prevention.
2 Chugh SS, et al. J Am Coll Cardiol. 2004;44: Avert Organization:
3 Nichol G, et al. JAMA. 2008;300: Heart and Stroke Statistics Update. American Heart Association.

10. SCD Rates for Gender and Ethnicity
600
White
Black
502.7
American Indian/Alaska Native
500
Asian/Pacific Islander
407.1
400
336.1
Per 100,000 Standard US Population
258.8
270.5
300
212.6
200
130.0
100
153.4
Males
Females
Zheng ZJ, et al. Circulation. 2001;104(18):

11. Incidence of SCD by Age and Gender
Age Group
SCD Rate Per 100,000
500
1000
1500
2000
2500
3000
3500
4000
4500
> 84
Men
Women
Zheng ZJ, et al. Circulation. 2001;104:

12. SCA Resuscitation Success versus Time*10 20 30 40 50 60 70 80 90
100 1 2 3 4 5 6 7 8 9
% Success
*Non-linear
Time (minutes)
Chance of success reduced 7-10% each minute
Cummins RO. Annals Emerg Med. 1989;18:

13. SCA Chain of Survival Statistics
Even in the best EMS/early defibrillation programs, it is difficult to achieve high survival times due to any SCA events not being witnessed and the difficulty of reaching victims within 6-8 minutes.
48% to 58% SCAs not witnessed1,2
85% SCAs occur at home/non-public1
4.6% to 8% estimated SCA out-of-hospital survival1,2
1 Nichol G, et al. JAMA. 2008;300:
2 Chugh SS, et al. J Am Coll Cardiol. 2004;44:

14. Time Dependent Risk Risk of SCD after a clinical event is not linear
Risk of SCD and total cardiac death highest within months after index event
Survival curves show similar characteristics after:
Survival of CA
Diagnosis of heart failure
Unstable angina
Recent MI
Mortality is highest in the 1st month post MI in patients with <30% EF

15. Substrates for Sudden Cardiac Arrest
3/4 pts with SCD have CHD
Hypertrophic cardiomyopathy (HCM)
Dilated cardiomyopathy (DCM)
RV cardiomyopathy
Long QT Syndrome/short QT Syndrome/Brugada, etc...
Other (AS, MVP, WPW)

16. Substrates for Sudden Cardiac Arrest: Sudden Cardiac Arrest Survivors
Highest risk factor for Sudden Cardiac Arrest is prior SCA event
30 to 50% of SCA survivors will experience another SCA event within one year
First-degree relatives of SCA patients have a 50% higher risk of MI or primary cardiac arrest
Myerburg RJ. Heart Disease, 5th ed, Vol 1. Philadelphia: WB Saunders Co;1997:ch 24.
Fogoros RN. Practical Cardiac Diagnosis: EP Testing, 2nd ed. Blackwell Science, pp 172.
The AVID Investigators. N Engl J Med. 1997;337:
Myerburg RJ. Ann Intern Med ;119:
Demirovic J. Progr Cardiovasc Dis. 1994;37:39-48.
Friedlander Y. Circulation. 1998;97:

17. Substrates for Sudden Cardiac Arrest: Prior Episode of VT
VT in combination with syncope or a low ejection fraction (LVEF < 40%) leads to an increased risk of Sudden Cardiac Arrest
One-year risk of SCA - 20 to 50%
Myerburg RJ. Heart Disease, 5th ed, Vol 1. Philadelphia: WB Saunders Co;1997:ch 24.
Fogoros RN. Practical Cardiac Diagnosis: EP, 2nd ed. Blackwell Science, pp 172.
The AVID Investigators. N Engl J Med. 1997;337:

18. Substrates for Sudden Cardiac Arrest: Prior MI
Prior MI identified in as many as 75% of SCA patients
Prior MI raises the one-year risk of SCA by 5% as a single risk factor
Five-year risk of SCA is 32% for patients with all 3 risk factors:
Prior MI
Non-sustained, inducible, nonsuppressible VT
LVEF < 40% .
Myerburg RJ. Heart Disease, 5th ed,Vol 1. Philadelphia: WB Saunders Co;1997:ch 24.
De Vreede-Swagemakers JJ. J Am Coll Cardiol. 1997;30:
Kannel WB. Circulation. 1975;51:
Shen WK. Mayo Clin Proc. 1991;66:
Bigger JT. Circulation. 1984;69:
Ruberman W. Circulation. 1981;64:
Buxton AE. N Engl J Med. 1999;341:

19. Substrates for Sudden Cardiac Arrest: Coronary Artery Disease
Extensive CAD is seen in approx 75% SCA patients
3-4 vessel disease
Autopsies have shown acute changes e.g. thrombus, plaque disruption in >50%
Over 50% of SCA victims had no manifestations of CAD prior to the sudden death episode
SCA is the first sign of heart disease in 20-50% of cases
Futterman LG. Am J Crit Care. 1997;6:
Demirovic J. Progr Cardiovasc Dis. 1994;37:39-48.
Moss AJ. N Engl J Med. 1996;335:
Friedlander Y. Circulation. 1998;97:

20. Substrates for Sudden Cardiac Arrest: Heart Failure
About one-half of all deaths in heart failure patients are characterized as sudden due to arrhythmias
The risk of SCA increases as left ventricular function deteriorates (low LVEF)
Unexplained syncope has predicted SCA in patients in functional NYHA Class II - IV
Myerburg RJ. Heart Disease. 5th ed, Vol 1. Philadelphia: WB Saunders Co; 1997:ch 24.
Middlekauf HR. J Am Coll Cardiol. 1993;21:
Stevenson WE. Circulation. 1993;88:

21. Severity of Heart Failure Modes of Death
12%
24%
64%
CHF
Other
Sudden
Death
n = 103
NYHA II
26%
15%
59%
NYHA III
56%
11%
33%
n = 27
NYHA IV
MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). LANCET ;353:

22. Substrates for Sudden Cardiac Arrest: Hypertrophic Cardiomyopathy
Sudden cardiac death is the most common cause of death in patients with HCM
Prevalence of HCM is about 0.2% of the general population and about 10% of HCM patients are considered to be at high risk of SCA
Recent study showed that over a ten year period > 50% of high-risk patients would experience SCA
HCM is the most common cause of SCA in athletes under 35 years of age
EP testing of limited utility
Myerburg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 5th ed, Vol 1. Philadelphia: WB Saunders Co; 1997:ch 24.
Maron BJ. New Engl J Med. 2000;342:

23. Substrates for Sudden Cardiac Arrest: Arrhythmogenic Right Ventricular Cardiomyopathy
ARVC suspected in young pts (usually men) with RV arrhythmias
Syncope, presyncope, less frequently biventricular failure seen
VA typically LBBB morphology and ranges from NSVT, VT to VF
ECG typically shows precordial T wave inversion- v1-v3 and QRS >110 ms
Low voltage potentials (epsilon waves) following QRS are characteristic but rare
>50% have abnormal SAECG

24. Substrates for Sudden Cardiac Arrest: Arrhythmogenic Right Ventricular Cardiomyopathy
SCD is frequently the first manifestation 0.08% to 9%
SCD occurs relatively frequently during exercise or stress
SCD more common in those with gross RV abnormalities but can occur in those with only microscopic abnormalities
Certain genetic types may be associated with increased risk
Current state of knowledge- genetic testing does not contribute to risk stratification
May be increased risk if > 1 family member with SCD
EP testing of limited utility

25. Substrates for Sudden Cardiac Arrest: Long QT Syndrome
Idiopathic LQTS is a congenital disorder that may lead to unexplained syncope, seizures, and SCA
Patients either remain asymptomatic or are prone to symptomatic and potentially lethal arrhythmias
A positive family history of LQTS or SCA is present in 60% of LQTS patients
Due to the hereditary linkage, it is necessary to identify other family members at risk
Schwartz PJ. Curr Probl Cardiol. 1997;22:
Smith WM. Ann Intern Med. 1980;93:
Garson A Jr. Circulation. 1993;87:

26. Secondary Prevention of Sudden Cardiac Arrest

27. Patient Case #1 History 54 y.o. African-American female
Ischemic cardiomyopathy
NYHA Class I
LVEF 45% per echo at your institution
Long-time heavy smoker; has COPD
Compliant and stable on optimal medical therapy
Syncopal episodes; with documented episodes of VT

28. Patient Case #1 Clinical Decisions
Should this patient be referred for an ICD evaluation?
What factors enter into your decision?
Is there anything else you’d want to know before making the decision?

29. Arrhythmic Death in VT/VF Patients AVID Results in Non-ICD Arm20
18% 18 16 14
11% 12 10
% Arrhythmic Death 8% 8 6 4 2
1 Year
2 Years
3 Years
Pratt CM. Circulation. 1998;98(suppl I):

30. AVID Registry Study Survival by Arrhythmia Type
Unexplained syncope
Non -
syncopal
VT w/symptoms
1.00 VF
Transient correctable VT/VF
Asymptomatic VT
.90
VT w/syncope
Cumulative Survival (%)
.80
.70
P = 0.007
.65 1 2 3
Years
Anderson JL, et al. Circulation. 1999;99:

31. Randomized Clinical Trials
ICD Therapy for the Secondary Prevention of SCA
Mortality
(%)
Trial N
Mean Age (yrs)
Mean LVEF (%)
Follow-up (mos)
Control Therapy
Control
ICD P
AVID1
1016
65 ± 10 35
18 ± 12
Amiodarone or sotalol
24.0
15.8
.02
CIDS2
659
64 ± 9 34 36
Amiodarone
29.6
25.3
.14
CASH3
288
58 ± 11 45
57 ± 34
Amiodarone or metoprolol
44.4
36.4
.08
1 The AVID Investigators. N Engl J Med. 1997;337:
2 Kuck KH, et al. Circulation. 2000;102:
3 Connolly SJ, et al. Circulation. 2000;101:

32. Secondary Prevention Trials: Reduction in Mortality with ICD Therapy1 2 3
31%
56%
23%*
58%
20%*
33%
% Mortality Reduction w/ ICD Rx
Non-significant results.
1 The AVID Investigators. N Engl J Med. 1997;337:
2 Kuck Kh, et al. Circulation. 2000;102:
3 Connolly SJ, et al. Circulation. 2000;101:

33. 2008 ACC/AHA/HRS Class I ICD Secondary Prevention Guidelines for the Management of Ventricular Arrhythmias
History of SCA, VF, hemodynamically unstable sustained VT (exclude reversible causes)
Structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable
Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at EP study
Non-sustained VT due to prior MI, LVEF < 40% and inducible VT at EP study
Epstein AE, et al. Circulation 2008;117:e

34. Primary Prevention of Sudden Cardiac Arrest

35. Patient Case #2 History 52 y.o. woman
Moderate alcohol consumption, has stopped since MI
Lives alone in rural community
NYHA Class III
PMHX: MI one year ago, echo on discharge was 35%
Medications: BB, ACE-I, lipid-lowering agent, clopidorgrel, omega-3

36. Patient Case #2 Clinical Decisions
Should this patient be referred for an ICD evaluation?
What factors enter into your decision?
Is there anything else you’d want to know before making the decision?

37. SCA Relationship to HF and Reduced LVEF
Reduced left ventricular ejection fraction (LVEF) remains the single most important risk factor for overall mortality and SCD1
As HF progresses, pump failure (rather than SCA) becomes relatively more likely as the cause of death2
25% overall death in 2.5 years in HF patients and 50% die of SCA3
1 Prior SG, et al. Eur Heart J. 2001;22:
2 MERIT-HF Study Group. Lancet. 1999;353:
3Sweeney MO, PACE. 2001;24:

38. SCD Risks in HF Patients with LV Dysfunction50
Total Mortality 44 42 41
Sudden Cardiac Death
39.7 40 30
Control Group Mortality % 20 19 20 17 15 11 9 10 7 8 6 4
CHF-STAT
GESICA
SOLVD
V-HeFT I
MERIT-HF
CIBIS-II
CARVEDILOL-US
45 months
13 months
41.4 months
27 months
12 months
16 months
6 months
Total Mortality ~15 to 40%; SCD accounts for ~50% of Total Deaths

39. Relation of LVEF to Risk of SCA
Note: 56.5% of all SCA
victims had an LVEF > 30%
7.5% 8 7 6
5.1% 5
% Sudden Cardiac Deaths 4
2.8% 3 2
1.4% 1
0-30%
31-40%
41-50%
> 50%
LVEF
deVreede-Swagemakers JJ, et al. J Am Coll Cardiol. 1997;30:

40. Severity of Heart Failure Modes of Death
NYHA II
NYHA III
CHF
CHF
12%
Other
26%
Other
24%
Sudden
59%
64%
Death
15%
Sudden
(N = 103)
Death
(N = 103)
NYHA IV
CHF
SCA
Pump Failure
NYHA Class II
64%
12%
NYHA Class III
59%
26%
NYHA Class IV
33%
56%
33%
Other
56%
Sudden
11%
Death
(N = 27)
MERIT-HF Study Group. Lancet.1999;353:

41. SCA Relationship to MI
In people who’ve had an MI and have HF, SCD occurs at 4 times the rate of the general population.
Adabag AS, et al. JAMA. 2008;300:

42. Time Dependence of Mortality Risk Post-MI Prediction of Sudden Cardiac Death After Myocardial Infarction in the Beta-Blocking Era1
700 post-MI patients; ~ 95% on beta blockers 2 years after discharge.
The epidemiologic pattern of SCD was different from that reported in previous studies.
Arrhythmia events did not concentrate early after the index event; most occurred > 18 months post-MI.
Total Mortality 18 18 15 15 12
Cardiac Mortality 12
Cumulative Events (%) 9 9
Non-SCD 6 6
SCD 3 3 20 40 60 20 40 60
Follow-Up (months)
Follow-Up (months)
1 Huikuri HV, et al. J Am Coll Cardiol. 2003;42:

43. Relation of Time from MI to ICD Benefit in the MADIT-II Trial
% Mortality for Each Time Period
Time from MI
(n = 300)
(n = 283)
(n = 284)
(n = 292)
Hazard Ratio
.98
(p = 0.92)
0.52
(p = 0.07)
0.50
(p = 0.02)
0.62
(p = 0.09)
Wilber, D. Circulation. 2004;109:

44. SCD Rates in Post-MI Patients with LV Dysfunction32
Total Mortality 30 28 28
Arrhythmic Mortality 21 20
19.8 20 18 16 16
Control Group Mortality % at 2 years 14 12 10
9.4 10 7
TRACE
CAPRICORN
EMIAT
MADIT
MUSTT
MUSTT
MADIT II
Inducible
Registry
Total Mortality ~20 to 30%; SCD accounts for ~50% of Total Deaths

45. Randomized Clinical Trials Supporting Device Therapy
ICD and CRT-D for the Primary Prevention of SCA
Mortality (%)
Trial N
MeanAge (yrs)
Mean LVEF (%)
Mean
Follow-up (mos)
Control Therapy
Control
ICD P
SCD-HeFT 1,2
2,521
60.1 25
45.5
Optimal Medical Therapy
36.1
28.9
.007
COMPANION 3
1,520 67 21
months 19 12
(CRT-D)
.0003
MUSTT 4
704 30 39
No EP-guided Therapy 48 24
.06
MADIT II 5
1,232 64 23 20
19.8
14.2
1Bardy GH, et al. N Engl J Med. 2005;352:
2 Packer DL. Heart Rhythm. 2005;2:S38-S39
3 Bristow MR, et al. N Engl J Med. 2004;350:
4 Buxton AE, et al. N Engl J Med. 1999;341:
5 Moss AJ, et al. N Engl J Med. 2002;346:

46. % Mortality Reduction w/ ICD Rx
Primary Prevention Post-MI and HF Trials Reduction in Mortality with ICD or CRT-D Therapy 80
Overall Death 73
Arrhythmic Death 64 62 56 60 55 36
% Mortality Reduction w/ ICD Rx 40 31 23 20
1,2 3 4 5
SCD-HeFT
COMPANION
MUSTT
MADIT-II
1Bardy GH, et al. N Engl J Med. 2005;352:
2 Packer DL. Heart Rhythm. 2005;2:S38-S39
3 Bristow MR, et al. N Engl J Med. 2004;350:
4 Buxton AE, et al. N Engl J Med. 1999;341:
5 Moss AJ, et al. N Engl J Med. 2002;346:

47. Patient Case #3 History 68 y.o. male NYHA Class III
LVEF measured in 2006 was 37%
QRS 130 ms
PMHX: MI 12 years ago
Medications: BB, ACE-I, lipid-lowering agent
Just completed last round of chemotherapy for Pancreatic CA

48. Patient Case #3 Clinical Decisions
Should this patient be referred for a CRT-D evaluation?
What factors enter into your decision?
Is there anything else you’d want to know before making the decision?

49. 2008 ACC/AHA/HRS Class I Primary Prevention Guidelines for Management of Ventricular Arrhythmias: ICD and CRT-D
ICD Class I Guidelines
LVEF < 35% due to prior MI; who are at least 40 days post-MI; and are in NHYA Class II or III
Nonischemic DCM who have an LVEF < 35% and who are in NYHA Class II or III
LV dysfunction due to prior MI how are at least 40 days post-MI; have an LVEF < 30%; and are in NHYA Class I
CRT-D Class I Guideline
LVEF < 35%; a QRS duration > 0.12 seconds; and sinus rhythm; and NHYA Class III or ambulatory IV and on optimal medical therapy
Epstein AE, et al. Circulation 2008;117:e350-e408.

50. ICD Contraindications
Patient Class III contraindications for ICD or CRT-D:
Not expected to survive with an acceptable functional status for at least one year
Incessant VT or VF
Significant psychiatric illness that may be aggravated by device transplant or preclude systematic follow-up
NYHA Class IV with drug-refractory HF, who are not candidates for cardiac transplantation or CRT-D
Syncope of undetermined cause without inducible VT and without structural heart disease
VT or VF that is amenable to surgical or catheter ablation
Patients whose VTs due to a completely reversible cause in the absence of structural heart disease
Questions
Are there patients who are indicated but who should not get an ICD?
Who makes the decision on whether or not an ICD is offered?
Epstein AE, et al. Circulation. 2008;117:e350-e408.

51. Summary

52. Summary SCA is a leading cause of death in the United States.
Defibrillation is the only effective treatment for SCA.
Few SCA victims are treated quickly enough to survive.
Patients at risk of SCA need to be identified PRIOR to an SCA event to increase survival rates.

53. Summary
High risk SCA patients can be identified: low LVEF, HF, prior MI and prior SCA or VT/VF event.
ICD and CRT-D therapies can prevent SCA.
Many eligible patients are not receiving device therapy.

54. Detailed 2008 ACC/AHA/HRS Guidelines
Appendix
Detailed 2008 ACC/AHA/HRS Guidelines

55. ICD Guidelines Focused on Secondary Prevention of SCA
Survivors of cardiac arrest due to VF or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes. Class I, Evidence A
Patients with structural heart disease and spontaneous sustained VT, whether hemodynamically stable or unstable. Class I, Evidence B
Patients with syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at EP study. Class I, Evidence B
Epstein AE, et al. Circulation. 2008;117:e

56. ICD Guidelines Focused on Secondary Prevention of SCA
Patients with nonsustained VT due to prior MI; LVEF < 40%; and inducible VF or sustained VT at EP study. Class I, Evidence B
Patients with sustained VT and normal or near-normal ventricular function. Class IIa, Evidence C
Patients with catecholaminergic polymorphic VT who have syncope and/or documented sustained VT while receiving beta blockers. Class IIa, Evidence C
Epstein AE, et al. Circulation. 2008;117:e

57. ICD Guidelines Focused on the Primary Prevention of SCA
Patients with LVEF < 35% due to prior MI who are at least 40 days post-MI and are in NYHA Class II or III. Class I, Evidence A
Patients with nonischemic DCM who have an LVEF < 35% and who are in NYHA Class II or III. Class I, Evidence B
Patients with LV dysfunction due to prior MI who are at least 40 days post-MI, have an LVEF < 30%, and are in NYHA Class I Class I, Evidence B
Patients with unexplained syncope, significant LV dysfunction, and nonischemic DCM. Class IIa, Evidence C
Epstein AE, et al. Circulation. 2008;117:e350-e408.

58. ICD Guidelines Focused on Primary Prevention of SCA
Non-hospitalized patients awaiting transplantation. Class IIa, Evidence C
Patients with nonischemic heart disease who have an LVEF < 35% and who are in NYHA Class I. Class IIb, Evidence C
Patients with syncope and advanced structural heart disease in whom thorough invasive and noninvasive investigations have failed to define a cause. Class IIb, Evidence C
Patients with LV non-compaction. Class IIb, Evidence C
Epstein AE, et al. Circulation. 2008;117:e

59. ICD Guidelines for Hereditary Diseases
Patients with Long QT syndrome who are experiencing syncope and/or VT while receiving beta blockers. Class IIa, Evidence B
Patients with HCM who have one or more major risk factors for SCD. Class IIa, Evidence C
Patients with arrhythmogenic right ventricular dysplasia/ cardiomyopathy (ARVD/C) who have one or more risk factors for SCD. Class IIa, Evidence C
Epstein AE, et al. Circulation. 2008;117:e350-e408.

60. ICD Guidelines for Hereditary and Other Conditions
Patients with Brugada syndrome who have had syncope Class IIa, Evidence C
Patients with Brugada syndrome who have documented VT that has not resulted in cardiac arrest. Class IIa, Evidence C
Patients with cardiac sarcoidosis, giant cell myocarditis, or Chagas’ disease. Class IIa, Evidence C
ICD therapy may be considered for patients with Long QT syndrome and risk factors for SCD. Class IIb, Evidence C
ICD therapy may be considered in patients with a familial cardiomyopathy associated with sudden death Class IIb, Evidence C
Epstein AE, et al. Circulation. 2008;117:e

61. CRT/CRT-D Guidelines
Patients with LVEF < 35%, a QRS duration > 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of NYHA Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. Class I, Evidence A
Patients with LVEF < 35%, a QRS duration > 0.12 seconds, and AF, CRT with or without an ICD is reasonable for the treatment of NYHA Class III or ambulatory Class IV heart failure symptoms on optimal recommended medical therapy. Class IIa, Evidence B
Patients with LVEF < 35% with NYHA Class III or ambulatory Class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, CRT is reasonable. Class IIa, Evidence C
Epstein AE, et al. Circulation. 2008;117:e

62. CMS ICD Coverage Secondary Prevention Indications
Documented episode of cardiac arrest due to VF not due to a transient or reversible cause;
Documented sustained VT, either spontaneous or induced by an EP study, not associated with an acute MI and not due to a transient or reversible cause

63. CMS ICD Coverage Primary Prevention Indications
Documented familial or inherited conditions with a high risk of life-threatening VT, such as Long QT syndrome or hypertrophic cardiomyopathy;
CAD with a documented prior MI, a measured LVEF ≤ 0.35, and inducible, sustained VT or VF at EP study. (MI must have occurred more than 40 days prior to defibrillator insertion. EP test must be performed > 4 weeks after the qualifying MI.);
Documented prior MI and a measured LV EF ≤ 0.30;

64. CMS ICD/CRT-D Coverage Primary Prevention Indications
Ischemic dilated cardiomyopathy (IDCM), documented prior MI, NYHA Class II and III HF, and measured LV EF ≤ 35%;
Nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III HF, and measured LV EF ≤ 35% (if registered into ICD Registry); and
Meet all current CMS coverage requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV HF