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In Reply: Dr Soliman agrees that risk-benefit ratios need to be established for ICDs for primary prevention in the Medicare population and extends this quandary to the entire population. He outlines the challenges of defining a population at high enough risk of sudden cardiac death so that the benefit of an ICD will outweigh the risks. Current risk-prediction models are not precise, and in general, the risk of sudden cardiac death is much lower for primary prevention than for secondary prevention. Thus, about 17% to 25% of primary prevention ICD recipients receive any shock, and they are twice as likely to receive an inappropriate shock as an appropriate shock.¹ The benefit of appropriate shock must be balanced against the risks of implantation and of inappropriate shock, the decrement in quality of life,² and the anxiety engendered in healthy patients who learn that their implanted lead had been recalled, an increasingly . . . [Full Text of this Article]

Rita F. Redberg, MD, MSc
redberg@medicine.ucsf.edu
Division of Cardiology
School of Medicine
University of California, San Francisco

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