Sudden death is a devastating complication of heart failure (HF). Current guidelines recommend an implantable cardioverter-defibrillator (ICD) for 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 a benefit of prophylactic ICD implantation in patients with HFrEF of non-ischaemic aetiology is less strong. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) block the deleterious actions of angiotensin II, norepinephrine, and aldosterone, respectively. Neprilysin inhibition potentiates the actions of endogenous natriuretic peptides that mitigate adverse ventricular remodelling. BB, MRA, angiotensin receptor–neprilysin inhibitor (ARNI) have a favourable effect on reduction of sudden cardiac death in HFrEF. Recent data suggest a beneficial effect of sodium–glucose cotransporter 2 inhibitors (SGLT2i) in reducing serious ventricular arrhythmias and sudden cardiac death in patients with HFrEF. So, in the current era of new drugs for HFrEF and with the optimal use of disease-modifying therapies (BB, MRA, ARNI and SGLT2i), we might need to reconsider the need and timing for use of ICD as primary prevention of sudden death, especially in HF of non-ischaemic aetiology.

中文翻译：

---

预防射血分数降低的心力衰竭猝死：我们还需要植入式心脏复律除颤器进行一级预防吗？


猝死是心力衰竭（HF）的一种毁灭性并发症。目前的指南建议使用植入式心律转复除颤器 (ICD) 来预防心力衰竭和射血分数降低 (HFrEF) 患者的猝死，特别是那些在经过至少 3 个月的优化心力衰竭治疗后左心室射血分数≤35% 的患者。 ICD 对冠状动脉疾病引起的症状性 HFrEF 患者的益处已得到充分证明。然而，关于非缺血性 HFrEF 患者预防性植入 ICD 的益处的证据并不充分。血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、β-阻滞剂 (BB) 和盐皮质激素受体拮抗剂 (MRA) 分别阻断血管紧张素 II、去甲肾上腺素和醛固酮的有害作用。脑啡肽酶抑制可增强内源性利尿钠肽的作用，从而减轻不良心室重塑。 BB、MRA、血管紧张素受体-脑啡肽酶抑制剂（ARNI）对减少 HFrEF 心源性猝死具有良好的作用。最近的数据表明，钠-葡萄糖协同转运蛋白 2 抑制剂 (SGLT2i) 对于减少 HFrEF 患者的严重室性心律失常和心源性猝死具有有益作用。因此，在当前 HFrEF 新药出现和最佳​​使用疾病缓解疗法（BB、MRA、ARNI 和 SGLT2i）的时代，我们可能需要重新考虑使用 ICD 作为猝死一级预防的必要性和时机，特别是非缺血性心力衰竭。