Advanced pharmacologic and interventional therapies have improved survival in heart failure. Implantable cardioverter-defibrillators (ICD) have been shown to reduce mortality in patients with heart failure, but the benefit appears to be uneven in this population. We reviewed the evidence showing the benefit of ICD therapy in heart failure patients, the main issues arising from these studies, and the possible answers for a better risk stratification. In addition, we showed that multimodality imaging could improve patient selection for the implantation of ICDs, in both primary and secondary prevention, beyond the selection using only the left ventricular ejection fraction, by concentrating on arrhythmic substrate.
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