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(Circulation. 2006;114:101-103.)
© 2006 American Heart Association, Inc.

Editorial

Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Death in Heart Failure

Are There Enough Bangs for the Bucks?

Lynne Warner Stevenson, MD

From Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass.

Correspondence to Lynne Warner Stevenson, MD, Brigham and Women’s Hospital, Cardiovascular Division, 75 Francis St, Boston, MA 02115.

Key Words: Editorials • cardiomyopathy • death, sudden • defibrillation • heart failure • defibrillators, implantable

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
The demonstrated efficacy of implantable cardioverter-defibrillators (ICDs) for reducing sudden death in heart failure trial populations presents a critical challenge to those responsible for the allocation of healthcare resources.^1–3 The current cost, multiplied by the prevalence of heart failure deemed high-risk, threatens to make this one enterprise the highest priced intervention for the Medicare population. The elegant cost-effectiveness analysis contributed by Dr Mark and colleagues from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) in this issue of Circulation provides an exemplary insight into this challenge.⁴ These investigators’ favorable conclusions are consistent with those from a meta-analysis by Sanders et al⁵ and with the slightly more conservative implications from the recent cost-effectiveness analysis of the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II by Zwanziger et al.⁶

Article p 135

This editorial will offer an alternative conclusion based on both back-of-the-envelope estimations and scrutiny of model assumptions regarding different phases of survival for heart failure populations. ICDs for primary prevention of sudden death in the heart failure population may be less cost-effective than other recommended heart failure therapies, which are prescribed to modify disease progression and symptoms, decreasing costly hospitalizations as well as mortality.

	The Back of the Envelope

 
Formal cost-effectiveness analysis is complex, but it may be illustrative to begin from simple considerations. A reasonable threshold for cost-effective intervention is often assigned as $40 000 per life-year saved, in line with the present article⁴ suggesting a cost of $38 389 per life-year saved and $41 530 per quality-adjusted life-year saved. This is approximately equal to . . . [Full Text of this Article]

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