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Hypertrophic cardiomyopathy is a highly variable disease that is often benign but can be lethal. Implantable cardioverter defibrillators reduce the risk of lethal arrhythmias, but not everyone needs one, and selecting the patients most likely to benefit remains a challenge. In one international cohort, a fifth of patients with hypertrophic cardiomyopathy were rescued by their devices during a mean follow-up of 3.7 years. The chances of an appropriate shock were about the same for those with one, two, or more risk factors for sudden death, and the study's authors conclude that even patients with only one risk factor should be considered for treatment.
An accompanying editorial is more cautious, however (p 452). In this study of 506 people, there were 19 (4%) infections, eight (2%) episodes of bleeding or thrombosis, and 34 (7%) lead problems such as fractures. One patient died when their device didn't work and 136 patients (27%) were shocked inappropriately. Weighing up the risks and benefits, a defibrillator should be offered to anyone with a history of sustained ventricular tachycardia or cardiac arrest, says the editorial. Patients with two or more risk factors for sudden death may benefit too, but all decisions must be preceded by detailed discussions of the patient's views on procedures, implantable devices, and risk.