Contemporary Use of Implantable Cardioverter-Defibrillators in the Era of 4-Pillar Heart Failure Therapy---an International Survey.

Background: Optimized 4-pillar guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) has significantly altered clinical practice, with a coinciding decrease in sudden cardiac death. The continued role for implantable cardioverter-defibrillators (ICDs) in primary prevention of sudden death has recently been debated in the context of residual arrhythmic risk. This survey explored contemporary attitudes toward primary prevention ICD use in ischemic and nonischemic cardiomyopathy. Methods: An international, REDCap-based survey targeting clinicians involved in HFrEF management assessed the impact of GDMT on ICD decision-making, clinical thresholds used for implantation, and willingness to participate in randomized controlled trials. Results: Of 210 registered responses, 140 (66.7%) could be analyzed. Most respondents were electrophysiologists (77.1%) working in academic centers (70.7%) in North America (87.1%). Fewer ICD implantations were reported after the introduction of 4-pillar GDMT, with a larger reduction in nonischemic cardiomyopathy ( Conclusions: In the era of optimized GDMT, practice patterns regarding primary prevention ICD implantation are increasingly heterogeneous. These findings underscore the need for nuanced shared decision-making and well-designed randomized controlled studies to guide future practice.