Patients’ Attitudes and Perceptions of Implantable Cardioverter-Defibrillators: Potential Barriers to Appropriate Primary Prophylaxis


  • Financial Support: This study was funded as an Investigator-Initiated grant by Medtronic, Inc. to Dr. Lampert.

Address for reprints: Rachel Lampert, M.D., F.H.R.S., Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar Street, FMP 3, New Haven, CT 06520. Fax: 203-785-7144; e-mail:


Background: Primary prophylaxis with implantable cardioverter-defibrillators (ICDs) improves mortality in patients at risk for sudden cardiac death (SCD). However, ICDs are highly underutilized. We explored patients’ attitudes and perceptions of ICDs to better understand potential patient-related barriers to appropriate utilization.

Methods: Records of patients visiting three outpatient cardiology clinics (June 2009–January 2010) were reviewed and 133 with ejection fractions ≤35% and without an ICD were identified. Seventy-two met criteria for ICD placement. Twenty-five consented and were interviewed by telephone using a semistructured open-ended interview guide. Twelve individuals had accepted ICD referral, and 13 had declined. We analyzed transcripts of ICD refusers and acceptors using the constant comparative method of grounded theory.

Results:  Five major themes emerged: (1) Patients who refused ICD referral demonstrated a lack of insight into their own risk potential. (2) Many patients who accepted ICD referral perceived that this was strongly recommended by their physicians, although many patients refusing did not. (3) Concerns over recall, malfunction, and surgical risk were common in both. (4) Many patients demonstrated inaccurate perceptions of ICD-related risks and lifestyle changes. Acceptors often reported these perceptions being addressed by their physician. (5) Feelings regarding invasive life-prolonging interventions played an important role in ICD referral refusal for some individuals.

Conclusions: Refusal of ICD is common among primary prevention candidates. Common themes in the decision-making process include insight into personal risk of SCD, and perceived strength of the physician recommendation. Providers may want to consider assessment of patients’ individual understanding and perceptions when discussing ICD prophylaxis. (PACE 2012; 35:1179–1187)