UK could double patients receiving implantable defibrillators

19 December 2005

The UK body responsible for national guidance on health treatments, the National Institute for Health and Clinical Excellence (NICE), is expected to publish guidance this month that could dramatically increase the number of people in England and Wales who receive implantable-cardioverter defibrillators (ICDs), life-saving medical devices for people at risk of sudden cardiac arrest.

The UK has one the lowest rates of ICD use in the developed world. Dr Derek Connelly, President of the physician group Heart Rhythm UK, commended NICE for its updated ICDs guidance, which could double the number of people who are fitted with the implantable devices. But he warned that the guidance will require a push from the NHS to ensure that its implementation follows quickly and evenly across England and Wales.

Dr Connelly commented: "NICE's new guidance on ICDs is good news for those at risk of sudden cardiac arrest, which currently kills 90,000 people every year in the UK. It means that, going forward, many more people with heart conditions that make them especially prone to sudden cardiac arrest should be fitted with ICDs prophylactically. But without a clear steer from the NHS, the guidance will likely languish and end up having a negligible impact on clinical practice. That would be more than a shame. After all, people's lives are at stake."

The guidance extends the provision of ICDs for primary prevention of sudden cardiac arrest — that is, for people who have not experienced, but are deemed at high risk of, sudden cardiac arrest. For heart attack survivors who have a severely damaged heart, clinicians can opt under the new guidance to use a combination of two non-invasive measures before deciding on an ICD: left ventricular ejection fraction (LVEF) and QRS duration.

The guidance will make no significant difference to the provision of ICDs for secondary prevention of sudden cardiac arrest — that is, for people who have survived a sudden cardiac arrest or have had a prolonged life-threatening rhythm disturbance of the heart.

The guidance also makes no provision for patients with a common form of heart muscle disease called dilated cardiomyopathy, who might also be at risk of sudden death, and who have as much to gain from ICD therapy as those who have had a severe heart attack.

According to Dr Connelly, a consultant cardiologist at Glasgow Royal Infirmary and a trustee of Arrhythmia Alliance, the UK's heart rhythm charity: "Patients with dilated cardiomyopathy have been ignored by NICE. Clinical trials tell us that their risk of sudden death is as high as that of patients with coronary heart disease, and that ICDs can also save their lives. Patients and families with this condition will be disappointed that NICE have chosen not to recommend treatment for them".

Less than 20,000 people in the UK have been fitted with ICDs since the mid-1990s, and the country's current implant rate remains among the lowest in the industrialised world, at 50 people per million population — or 3,000 per year. In Western Europe the rate stands at 85 per million and in the US at 400 per million. NICE's draft guidance on ICDs could double the current implant rate to 100 per million in England and Wales.

ICDs save lives. Fitted in the chest by cardiologists specialising in electrophysiology (EP), also called heart rhythm specialists, they sense dangerously fast heart rhythms that lead to sudden cardiac arrest and can convert the heart back into a normal rhythm, whether by pacing or by delivering a shock. ICDs might also improve quality of life by giving patients the confidence to live life to the full, without the fear of sudden death.

ICDs represent a small proportion of NHS expenditures on heart disease. Last year, for example, the NHS spent £700m on statins, the cholesterol-lowering drugs, compared to £30m on ICDs. If the current implant rate in the UK continues to increase at 15 per cent per year, it would take five years for the number of ICD implants to double, from 3,000 to 6,000. Arrhythmia Alliance wants to work with Government to accelerate the rate of uptake for these life-saving medical devices.

Links
Arrhythmia Alliance: www.arrhythmiaalliance.org.uk
National Institute for Health and Clinical Excellence (NICE): www.nice.org.uk

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