Primary-Prevention ICDs in LMICs: Lifesaving or burden?

 At the 7th Karachi Electrophysiology Summit 2026, I presented a practical framework for the use of primary-prevention implantable cardioverter-defibrillators (ICDs) in low- and middle-income countries.

The presentation examined the tension between established survival benefit and the realities of limited resources, out-of-pocket expenditure, competing mortality and the need for lifelong device follow-up. The central argument was that ICD therapy should not be reduced to an ejection-fraction threshold alone.

A high-value ICD pathway requires appropriate arrhythmic substrate, correct timing after guideline-directed medical therapy and revascularization, a reasonable survival horizon, low competing mortality, and a health system capable of providing safe implantation, programming, surveillance, complication management and generator replacement.

The conclusion: primary-prevention ICDs remain lifesaving therapy when they are targeted, timed and supported. The appropriate LMIC strategy is selective access rather than blanket denial, with the aim of maximizing lives saved per device.

 On 30 July 2026, I presented an educational heart-failure case at the KICKOFF KITE Scientific Forum at Pearl Continental Hotel, Rawalpindi, focusing on the management of acute decompensated HFrEF complicated by atrial fibrillation with rapid ventricular response.

The session used the KITE framework - Know the Patient, Interpret the Evidence, Translate into Practice, Elevate Outcomes - to move from the first few minutes of a high-risk presentation through emergency rhythm management, treatment of precipitating infection and congestion, initiation of guideline-directed medical therapy, discharge planning, and longer-term reassessment for rhythm and device therapy.

A central theme of the presentation was that acute heart failure, atrial fibrillation and infection should not be treated as separate problems. In a patient who is hypoxic, hypotensive and in pulmonary oedema, the rhythm may itself be part of the haemodynamic emergency. Management therefore requires rapid recognition of the clinical phenotype, treatment of the trigger, appropriate rhythm rescue, careful decongestion, and structured follow-up.

• Recognise the phenotype: congestion, hypoxaemia and low blood pressure identify a high-risk acute heart-failure presentation.
• AF may be the emergency: unstable atrial fibrillation in pulmonary oedema may require urgent synchronized cardioversion rather than prolonged attempts at rate control.
• Treat the trigger: infection, arrhythmia and heart failure frequently amplify one another and should be managed as one clinical pathway.
• Start recovery before discharge: once haemodynamics, renal function and electrolytes permit, the four foundations of HFrEF therapy should be introduced and progressively titrated.
• Follow-up is treatment: early review, laboratory monitoring, therapy titration and repeat assessment of LV function determine longer-term rhythm and device decisions.

The presentation also highlighted the importance of allowing a recovery window before making primary-prevention ICD or CRT decisions, unless another urgent indication exists. The emphasis throughout was on turning a complex admission into a repeatable, multidisciplinary pathway that can improve outcomes beyond the index hospitalization.

Speaker: Dr Qurban Hussain Khan, FHRS
Assistant Professor of Cardiac Electrophysiology
Medical Superintendent, Rawalpindi Institute of Cardiology

 Dr Qurban Hussain Khan delivered an invited electrophysiology teaching session at the Pre-CardioCon 2026 ECG Workshop - Complex ECG Decoded, held at the Cardiac Center, PIMS, Islamabad.

The presentation focuses on one of the most important diagnostic challenges in acute arrhythmia care: the assessment of regular wide-complex tachycardia and the distinction between ventricular tachycardia (VT) and supraventricular tachycardia (SVT) with aberrant conduction.

At the centre of the presentation is a practical A-B-C-D-E approach to ECG interpretation:

• A - Axis: assessment for extreme or "northwest" axis deviation.
• B - Broad complexes: recognition of marked QRS prolongation.
• C - Concordance: identification of positive or negative precordial concordance.
• D - Dissociation: assessment for AV dissociation, capture beats and fusion beats.
• E - Early QRS: examination of the initial part of ventricular activation for features favouring VT or SVT with aberrancy.
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The presentation then applies this framework through a series of interactive ECG cases. These examples highlight the differential diagnosis of broad-complex tachycardia and include ventricular tachycardia as well as important mimics such as pre-excitation, electrolyte disturbance, ventricular pacing and SVT with aberrancy.

The aim of the session is to provide cardiologists, physicians and trainees with a structured and memorable approach to wide-complex tachycardia, combining clinical probability with a focused assessment of ECG morphology.

Clinical context matters. A history of myocardial infarction, structural heart disease and increasing age makes VT more likely in a patient with regular wide-complex tachycardia.

No single feature should be interpreted in isolation. The A-B-C-D-E approach provides a systematic way of looking for multiple ECG features that support a diagnosis of VT.

Pattern recognition improves with practice. The interactive cases reinforce the framework by asking the reader to distinguish VT from common mimics.

Presented by:
Dr Qurban Hussain Khan, FHRS
Assistant Professor of Cardiac Electrophysiology
Medical Superintendent, Rawalpindi Institute of Cardiology