Technology at the Crossroads with Care and Costs: The Implantation of the Automatic Internal Cardiac Defibrillator

Authors: George Ritter, MD, FACP, FACC


The automatic internal cardiac defibrillator (AICD, ACD or ICD) represents one of the biggest challenges in medical practice in these days of reduced reimbursements, increased financial pressures, increasingly complex technology, and growing malpractice litigation. It has been proved most valuable in aborting sudden cardiac death (SCD), and has saved thousands of lives. SCD is a threat in every patient with heart disease, so theoretically every cardiac patient is a candidate for an AICD. SCD is responsible for more than 250,000 deaths in this country annually, the incidence being highest in those with congestive heart failure.1 Proper use of the AICD requires careful patient selection. Medicare will reimburse for this device if certain criteria are met. The majority of patients at highest risk for SCD are those with coronary artery disease with or without prior myocardial infarction, especially if there has been congestive failure (CHF). The criteria for Medicare reimbursement have been changing year by year, and lately include an ejection fraction (EF) at or below 30% and a left ventricular activation time (QRS) of more than 120 ms. These criteria are unduly restrictive and arbitrary, as Drs. Ashwath and Sogade have shown in their report in this issue of the Southern Medical Journal.2The implication is that those who meet the criteria are at high risk and those who do not meet them are at low risk. Unfortunately, nothing could be farther from the truth.

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