Opportunities and Gaps in Guideline-Directed Defibrillator Therapy - 2025 Quality Summit Presentation (Non-CE)-Opportunities and Gaps in Guideline-Directed Defibrillator Therapy

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Video Summary

Dr. Takeki Suzuki, a cardiac electrophysiologist at Wake Forest, presented on opportunities and gaps in guideline-directed defibrillator therapy, focusing on primary prevention implantable cardioverter-defibrillators (ICDs) in heart failure with reduced ejection fraction (HFrEF). He emphasized that ICDs prevent sudden cardiac death by detecting and correcting ventricular arrhythmias and that their use should be guided by established guidelines, including the 2017 ventricular arrhythmia guideline, 2022 heart failure management guideline, and the recent 2025 Appropriate Use Criteria (AUC).<br /><br />Dr. Suzuki detailed guideline recommendations for primary prevention ICDs, stressing that ICD implantation is generally appropriate for patients with ischemic or non-ischemic cardiomyopathy with ejection fraction under 35%, after at least three months of optimized guideline-directed medical therapy (GDMT). GDMT includes ACE inhibitors/ARBs or ARNI, beta blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, all shown in landmark trials to reduce mortality and hospitalization in HFrEF.<br /><br />He highlighted the importance of identifying gaps in ICD utilization using registries like the National Cardiovascular Data Registry (NCDR) and tracking performance metrics to improve care quality. The 2025 AUC update expanded coverage to 335 clinical scenarios, including new device types like subcutaneous and extravascular ICDs, conduction system pacing, and increased emphasis on shared decision-making, especially in borderline cases.<br /><br />A panel discussion addressed challenges in distinguishing appropriate device use from documentation issues, the role of shared decision-making and its documentation, and considerations around inpatient vs. outpatient ICD implantation. They underscored the need for clear documentation, patient-centered discussions including risks and benefits, and involvement of palliative care when appropriate. The session concluded that while ICD indications remain largely unchanged, evolving therapies and technologies require continuous quality improvement and updated clinical tools for decision support.

Keywords

intravascular imaging

percutaneous coronary intervention

PCI

IVUS

OCT

cardiovascular care

plaque assessment

stent placement

cardiac interventions

implantable cardioverter-defibrillator

heart failure with reduced ejection fraction

primary prevention

guideline-directed medical therapy

ventricular arrhythmia guidelines

appropriate use criteria 2025

National Cardiovascular Data Registry

shared decision-making

subcutaneous ICD

quality improvement