Patient Preference in the Decision to Place Implantable Cardioverter-Defibrillators

Randomized controlled trials demonstrate that implantable cardioverter-defibrillators (ICDs) reduce mortality in certain patients with symptomatic heart failure and no history of sudden cardiac death (SCD).1 This trial evidence has led to guidelines recommending placement of an ICD for primary SCD prevention in patients with heart failure meeting specific criteria.2 More patients are receiving ICD therapy as indications for this therapy have expanded.3 However, ICDs are associated with important risks, including short-term procedural complications, the potential for worse quality of life if shocked, and increased hospitalization rates.4,5 Not surprisingly, patient preferences around ICD therapy vary.5 Patients who are older, have multiple comorbidities, or live with a higher burden of daily symptoms may see a trade-off between sudden cardiac death and living longer.6 In some cases, a patient’s decision to forgo ICD therapy may create a conflict between the physician’s desire to do good (beneficence) and the patient’s preference (autonomy). We conducted a study to determine how physicians weigh patient preferences and the evidence of mortality benefit in their decision to recommend an ICD for primary prevention to potentially eligible patients.