Date of Award


Document Type


Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Dr. Mzee Ngunga

Second Supervisor/Advisor

Dr. Hasham Varwani

Third Supervisor/Advisor

Dr. Jasmit Shah


AKU-East Africa


Background: Sudden Cardiac Death (SCD) is a major cause of mortality among patients with cardiovascular disease accounting for about 50% of deaths. Several studies have demonstrated the safety and efficacy of Implantable Cardioverter-Defibrillator (ICD) implantation in both primary and secondary prevention of SCD in at-risk populations. Despite well-publicized guidelines, ICD implantation rates remain low particularly in Africa with a paucity of data regarding factors associated with non-uptake and reasons for implant refusal. The study aimed to characterize these factors and identify reasons for ICD refusal. Understanding these factors and reasons for non-implantation will provide an opportunity to optimize ICD uptake among eligible patients hence reducing sudden cardiac arrest.

Objective: The primary study objective was to determine the factors associated with the non-uptake of ICD among eligible patients evaluated at a referral center in Kenya. The secondary objective was to identify the reasons for the refusal of ICD implantation among eligible patients.

Methods: This was a retrospective study of heart failure patients seen from 2018 to 2020. Demographics, etiology of heart failure, comorbidities, NYHA functional class, primary physician, insurance status, and reasons for refusal of ICD implantation were abstracted. Eligibility was defined by the 2017 ACC/AHA/HRS guidelines. ICD non-recipient and ICD recipient groups were compared to determine predictors for non-uptake. Fisher's Exact test or Chi Squared was used to test for between categorical data and the Kruskal Wallis test was used to test the differences between continuous data. Reasons for ICD non-uptake among eligible patients were reviewed.

Results: Of the 206 ICD device-eligible patients, only 69 (33.5%) had an ICD implantation. Compared to ICD recipients, the majority of ICD non-recipients were of African race (91.2% vs. 79.7%; p=0.019) and rural dwellers (18.7% vs 8.2%; p=0.031). There were no significant differences in age and gender between the two groups. In comparison to ICD recipients, more ICD non-recipients lacked private insurance (42.3% vs 63.8%; p=0.005), had non-cardiology physicians (16.1% vs 5.8%; p=0.045), and non-ischemic cardiomyopathy (54.7% vs 36.4% p=0.014). The most common reason for refusal of ICD implantation was the inability to pay for the device.

Conclusion: ICDs are underutilized in Kenya. The majority of patients without ICD had no private insurance and had non-ischemic cardiomyopathy and non-cardiology primary physicians. Referrals of eligible patients to device-implanting cardiologists and subsidized ICDs are potential strategies for enhancing ICD device uptake.