Patient preference in the decision to place implantable cardioverter-defibrillators.

R andomized controlled trials demonstrate that implantablecardioverter-defibrillators(ICDs)reduce mortalityincertainpatientswithsymptomaticheart failureandnohistoryof suddencardiacdeath(SCD). This trialevidencehasledtoguidelinesrecommendingplacement ofanICDforprimarySCDprevention inpatientswithheart failure meeting specific criteria. More patients are receivingICDtherapyasindicationsforthistherapyhaveexpanded. However, ICDsareassociatedwith important risks, including short-term procedural complications, the potential for worse quality of life if shocked, and increased hospitalizationrates.Notsurprisingly,patientpreferencesaroundICD therapyvary. Patientswhoareolder,havemultiplecomorbidities,or livewithahigherburdenofdailysymptomsmay seea trade-offbetweensuddencardiacdeathand living longer. Insomecases, apatient’sdecisionto forgoICDtherapy may create a conflict between the physician’s desire to do good(beneficence)andthepatient’spreference(autonomy). We conducted a study to determine how physicians weigh patient preferences and the evidence of mortality benefit in their decision to recommend an ICD for primary prevention to potentially eligible patients.