The role of implantable cardioverter-defibrillators in the elderly.

The implantable cardioverter-defibrillator (ICD) is a cornerstone therapy for the prevention of sudden cardiac death (SCD). However, with the global population aging, the application of ICD therapy to elderly patients presents a significant clinical and ethical challenge. The main clinical trials that established the efficacy of ICDs largely excluded or underrepresented individuals over the age of 75, as well as those with significant frailty and comorbidities. We critically examine the evidence for primary and secondary prevention, highlighting the concept of competing risks of non-arrhythmic death, which attenuates the potential benefit of ICDs with advancing age. The risk-benefit ratio is further complicated by a heightened risk of procedural and long-term complications, including device-related infections and pocket integrity issues such as skin erosion. The decision to perform a generator replacement at the time of battery depletion is a crucial opportunity for a new goals-of-care discussion rather than a routine procedure, as evidence shows high mortality rates and a low likelihood of appropriate therapy post-exchange in the very elderly. Finally, we address the management of the ICD at the end of life, summarizing the ethical and legal consensus supporting device deactivation as a critical component of palliative care to prevent suffering from futile shocks. This review calls for a paradigm shift away from criteria based solely on left ventricular ejection fraction and chronological age towards a holistic, individualized approach integrating comprehensive geriatric assessment, comorbidity burden, and structured shared decision-making.