Clinical implementation of guidelines for cardioverter defibrillator implantation: lost in translation?

Purpose: Guidelines for implantation of cardioverter defibrillators (ICD) are increasingly including indications for primary prevention of sudden cardiac death in high-risk groups, where ICDs were traditionally implanted for secondary prevention. We performed a single-centre audit to evaluate adherence to the recent Dutch guidelines. Methods. All 1886 patients visiting a large regional Dutch teaching hospital (attending 1.8 to 2.0% of the Dutch population) in November 2005 were screened using the recently updated Dutch guidelines. Patients fulfilling these criteria were categorised as having an ICD indication for primary or secondary prevention. Results: 135 patients had an indication for ICD, 19 of whom had one or received one. Of the remaining 116 patients, 14 were 'new' to the department of cardiology. The 102 'known' patients had 466 doctor-patient contacts in the previous year, which averages 4.57 cardiology contacts per patient per year. Patients were more likely to receive an ICD for the secondary prevention of SCD (10/11, 91%) than for primary prevention (9/124, 7%). Conclusion: In a large regional teaching hospital in the Netherlands, only a small proportion of patients eligible for ICD implantation actually receive one. Cardiologists tend to implant ICDs for secondary prevention of SCD. The low ICD implantation rate for primary prevention of SCD may relate to logistics (e.g. permission to implant ICDs, the presence of an electrophysiology lab) or the perceived low cost-benefit ratio. Our results indicate that once the substantial backlog (13,500 ICDs) has been addressed, the annual implantation of new ICDs should rise from the current 125 to at least 5 10 per million inhabitants per year in the Netherlands.