Over, under, or just right? How do we interpret ICD utilization in the modern era?

Over 5 million individuals are afflicted with heart failure in the United States per year. Current guidelines based on the MADIT- I and II, MUSTT and SCDHeFT trials recommend the use of pharmacologic as well as implantable cardioverter defibrillator (ICD) therapy as Class I indications for the prevention of sudden cardiac death (SCD) in a subgroup of patients (depending on their ejection fraction, NYHA class, and a variety of other parameters). However, despite these guidelines, the use of ICDs has been reported as suboptimal in prior publications as well as in the article by Pillarisetti, et al in this issue of the Journal.