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One-third to one-half of patients with chronic, dilated heart failure will die suddenly or be resuscitated from a cardiac arrest or sustained ventricular tachycardia (VT).1–3 Implantable cardioverter-defibrillators (ICDs) offer excellent protection from sudden death by providing effective termination of the arrhythmia when it occurs, but they are not without problems. Approximately one-third of patients will experience some adverse effect, including inappropriate shocks, lead problems, and infection.4,5 The implantation and testing procedure occasionally precipitates hemodynamic deterioration.6 DDD or VVI pacing from the right ventricular lead of the ICD may have adverse hemodynamic effects, including increasing dyssynchrony of left ventricular contraction, and may have contributed to the aggravation of heart failure observed in the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II).7,8See p 565 As with any therapy, wider use in lower risk patients increases the number of patients who might not benefit but who still suffer adverse effects. On the other hand, many sudden deaths will be prevented, and the balance, to this point, has been positive. The substantial costs of the ICD hardware, implantation, and follow-up are also a concern. Thus, identifying those patients with depressed ventricular function who are most likely to benefit, or perhaps more importantly, those who are unlikely to benefit, is of interest.The development of tests to identify patients at high risk for fatal arrhythmias typically follows a progression (Table). Retrospective studies determine if a positive test is more common in known high-risk groups (eg, cardiac arrest survivors) compared with lower risk groups. Second, predictive accuracy is evaluated prospectively, often as a substudy of a larger trial. Finally, the test is used to select a high-risk group for testing of a therapy. Despite the extremely high efficacy of ICDs for terminating …

Predicting Sudden Death Risk for Heart Failure Patients in the Implantable Cardioverter-Defibrillator Age