Prevention of sudden death in heart failure with reduced ejection fraction: do we still need an implantable cardioverter‐defibrillator for primary prevention?

Sudden death is a devastating complication of heart failure (HF). Current guidelines recommend an implantable cardioverter‐defibrillator (ICD) for the prevention of sudden death in patients with HF and reduced ejection fraction (HFrEF), specifically those with a left ventricular ejection fraction ≤35% after at least 3 months of optimized HF treatment. The benefit of ICD in patients with symptomatic HFrEF caused by coronary artery disease has been well documented; however, the evidence for the benefit of prophylactic ICD implantation in patients with HFrEF of non‐ischaemic aetiology is less intense. In the current era of new drugs for HFrEF and with the optimal use of disease‐modifying therapies (BB, MRA, ARNI and SGLT2i), the authors might need to reconsider the need and timing for the use of ICD as primary prevention of sudden death, especially in HF of non‐ischaemic aetiology.