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Background  Optimal timing of implantation of an implantable cardioverter/defibrillator ( ICD ) after newly diagnosed heart failure is unclear given that late reverse remodelling may occur. We aimed to analyze left ventricular ejection fraction ( LVEF ) after diagnosis of an  LVEF  ≤35% during optimization of heart failure drug therapy.    Methods and Results  One hundred fifty‐six patients with newly diagnosed  LVEF  ≤35% receiving a wearable cardioverter/defibrillator ( WCD ) were analyzed.  WCD  was prescribed for 3 months until first re‐evaluation. Indications for prolongation of  WCD  wearing period instead of  ICD  implantation were: (1)  LVEF  at 3‐month visit 30% to 35%; (2) increase in  LVEF  of ≥5% compared to the last visit; and (3) nonoptimized heart failure medication. Mean  LVEF  was 24±7% at diagnosis and 39±11% at last follow‐up (mean, 12±10 months). Whereas 88 patients presented a primary preventive  ICD  indication ( LVEF  ≤35%) at 3‐month follow‐up, only 58 showed a persistent primary preventive  ICD  indication at last follow‐up. This delayed improvement in  LVEF  was related to nonischemic origin of cardiomyopathy, New York Heart Association functional class at baseline, heart rate, better  LVEF  after 3 months, and higher dosages of mineralocorticoid receptor antagonist. Twelve appropriate  WCD  shocks for ventricular tachycardia/ventricular fibrillation occurred in 11 patients. Two patients suffered from ventricular tachycardia/ventricular fibrillation beyond 3 months after diagnosis.    Conclusions  A relevant proportion of patients with newly diagnosed heart failure shows recovery of  LVEF  >35% beyond 3 months after initiation of heart failure therapy. To avoid untimely  ICD  implantation, prolongation of  WCD  period should be considered in these patients to prevent sudden cardiac death while allowing left ventricular reverse remodeling during intensified drug therapy.

journal of the american heart association

Avoiding Untimely Implantable Cardioverter/Defibrillator Implantation by Intensified Heart Failure Therapy Optimization Supported by the Wearable Cardioverter/Defibrillator—The  PROLONG  Study