Skill Checkup: A 71-Year-Old Man With History of Chronic Heart Failure Presents With Dyspnea, Rales, and Ankle Swelling

Marco Guazzi, MD, PhD


May 02, 2022

An implantable cardioverter-defibrillator (ICD) is recommended as primary prevention against the risk for sudden death and all-cause mortality in patients with symptomatic HF (NYHA class II-III) and an LVEF ≤ 35% despite at least 3 months of optimal medical therapy, as long as these patients have a life expectancy substantially longer than 1 year with good functional status. However, this recommendation does not extend to patients who have had a myocardial infarction in the past 40 days. ICDs can correct potentially lethal ventricular arrhythmias and can prevent bradycardia in transvenous systems.

Patients with an LVEF ≤ 35% who have a pacemaker or an ICD and still develop worsening HF despite optimal medical therapy and have a significant proportion of right ventricular pacing may be candidates for stepping up to cardiac resynchronization therapy (CRT).

Subcutaneous ICDs seem to be as effective as conventional ICDs, but patients must be carefully selected because this treatment option cannot treat bradyarrhythmia (except post-shock pacing) and cannot deliver antitachycardia pacing or CRT. Considering that this patient has bradyarrhythmia, this treatment option would not be appropriate.

A wearable ICD may be considered for patients with HF who are at risk for sudden cardiac death. However, it is not a long-term management strategy thus is usually used for a limited period or as a bridge to an implanted device.

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