A critical waiting period of ≈3 months is generally accepted in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF) outside the context of an acute myocardial infarction before reassessing left ventricular (LV) ejection fraction and considering implantable cardioverter-defibrillator (ICD) therapy. This time window is offered to allow optimization of guideline-directed medical therapy (GDMT) to promote LV reverse remodeling, which if above a certain threshold, would render the need for an ICD unnecessary. Consideration for an ICD after this time-frame is endorsed by major professional groups,¹ serves as a key quality and performance measure, and is deemed appropriate by the Appropriate Use Criteria for ICD therapy.² This duration also guides reimbursement schema, for example, the Centers for Medicare & Medicaid Services limit coverage for ICDs in nonischemic dilated cardiomyopathy to after this 3-month waiting period.

Perhaps it is time to lengthen this time-frame before ICD decision making in newly diagnosed patients with HFrEF. In many cases, 3 months are not sufficient to truly optimize GDMT and allow adequate chance for LV recovery. Evolving risks of sudden cardiac death (SCD), recent expansion of the heart failure (HF) therapeutic armamentarium, and greater focus on shared decision making all support extension of this time window. We summarize these converging lines of evidence and critically appraise the merits of extending this traditional waiting period. We contend that consideration for ICD implantation should only occur once GDMT has been achieved at target doses and may be deferred up to 1 year after diagnosis in appropriately selected patients. As the Centers for Medicare & Medicaid Services plan to update the national coverage determination regarding ICD implantation over the next year, we believe this issue is timely and topical to address.

Epidemiological studies³ and clinical trials⁴ during the past several decades …

对于新诊断的射血分数降低 (HFrEF) 的心力衰竭患者，在急性心肌梗死之外，在重新评估左心室 (LV) 射血分数并考虑植入式心脏复律除颤器 (ICD) 之前，通常接受约 3 个月的关键等待期） 治疗。提供这个时间窗口是为了优化指南指导的药物治疗 (GDMT)，以促进左心室逆重塑，如果超过某个阈值，则不需要 ICD。在此时间范围后考虑使用 ICD 已得到主要专业团体的认可， ¹作为一项关键的质量和绩效衡量标准，并被 ICD 治疗的适当使用标准认为是适当的。 ²此期限还指导报销方案，例如，医疗保险和医疗补助服务中心将非缺血性扩张型心肌病 ICD 的承保范围限制在 3 个月的等待期之后。

也许现在是时候在新诊断的 HFrEF 患者做出 ICD 决策之前延长这个时间范围了。在许多情况下，3 个月不足以真正优化 GDMT 并为 LV 恢复提供足够的机会。心源性猝死 (SCD) 风险的不断变化、心力衰竭 (HF) 治疗手段的近期扩展以及对共同决策的更多关注都支持延长这一时间窗口。我们总结了这些汇聚的证据，并批判性地评估了延长这一传统等待期的优点。我们认为，只有在达到目标剂量的 GDMT 后才应考虑 ICD 植入，并且在适当选择的患者中可以推迟至诊断后 1 年。由于医疗保险和医疗补助服务中心计划在明年更新有关 ICD 植入的全国覆盖范围确定，我们认为这个问题是及时且值得解决的问题。

过去几十年的流行病学研究³和临床试验⁴ …