The recent study by Zecchin et al is an important contribution to the debate regarding the appropriate timing of prophylactic implantable cardioverter-defibrillator (ICD) implantation for patients with idiopathic dilated cardiomyopathy (DC). They have shown that with optimal medical therapy, 2/3 of patients with DC and “SCD-HeFT [Sudden Cardiac Death in Heart Failure] criteria” at presentation did not maintain ICD indications 3 to 9 months later. We wish to extend these observations by showing that even in patients with advanced heart failure and very low left ventricular ejection fractions (LVEFs), intensive medical management without ICD implantation can be associated with an exceptionally low 1-year mortality and, in many cases, with an improvement of the LVEF to >35%.

In a disease management program for indigent patients with advanced heart failure, our enrollment criteria include recent hospitalization for acute decompensated heart failure and an LVEF ≤25%. Our interdisciplinary team sees patients within 5 days of hospital discharge and then at every 2 weeks initially with telephone contacts in between. By 2 to 2.5 months into enrollment, most patients are at or near target doses of β blockers. In addition to aggressive dose titrations of all evidence-based medications, we also focus on patient education and helping with patients’ socioeconomic needs.

From January 1, 2010, through December 31, 2010, we enrolled 41 new patients. The mean age was 56; 27% had ischemic cardiomyopathy. Forty-nine percent of patients had no medical insurance; 27% had substance abuse or addiction. All except 4 patients had heart failure hospitalizations just before enrollment. The mean LVEF at enrollment was 17.5%. Each patient was followed for ≥12 months. None of the patients received prophylactic ICDs in the first year of enrollment. Nonetheless, 40 of 41 were alive at 1 year, corresponding to an extremely low 1-year mortality rate of 2.44%. This was not an outlier, because in a similar survey 10 years ago, the 1-year mortality without ICDs of 27 newly enrolled patients with a mean LVEF of 18.3% was 0%. In contrast, the usual 1-year mortality of patients after heart failure hospitalizations ranges from 20% to 30%. The only patient in our 2010 cohort who died within 1 year was a woman with end-stage DC and an LVEF of 5%, who was not a candidate for advanced treatments because of myeloma, was receiving home milrinone infusion, and was under hospice care. Twenty-five of the 41 patients underwent repeat echocardiography at 1 year after enrollment. In those, the mean LVEF increased from 18.8% before enrollment to 36.3% at 1 year (absolute mean increase 17.5%, relative increase 93.1%). Fifty-two percent of patients achieved LVEFs >35%, which is outside the SCD-HeFT ICD indication range.

The study by Zecchin et al clearly demonstrated that with optimum medical management, many patients with original SCD-HeFT criteria for prophylactic ICD implantation did not maintain ICD indication at 3 to 9 months into treatment. Our data extend those observations by demonstrating that with aggressive medical management, even high-risk patients with severe symptoms and very low LVEFs at presentation can do well, have very low 1-year mortality, and have great improvement in the LVEF, in many cases moving them outside the ICD indication range.

There is considerable debate about the optimum timing of prophylactic ICD placement in patients with nonischemic DC. Our data suggest that for patients who are followed by an intensive disease management program, it may be prudent to pursue aggressive medical management without prophylactic ICD implantation for ≥1 year after a recent diagnosis of DC. Such a conservative approach, however, mandates site-specific continuous quality control and repeat assessment of the 1-year risk for sudden death of all patients who were not treated with ICDs.