Therefore, stable VT is likely a marker for a substrate capable of producing subsequent lethal CLINICAL STATEMENTS AND GUIDELINES 2. Small observational studies demonstrated high mortality and frequent appropriate ICD shocks in patients with syncope and NICM.S7.2.1-7 S7.2.1-9 The assumption that malignant VAs are the likely cause of syncope and that the ICD would be protec- tive has recently been challenged. In a subgroup analysis of SCD-HeFT that included 472 patients, the ICD did not reduce either recurrent syncope or the increased risk of mortality associated A subgroup analysis of the MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy) trial found syncope to be arrhythmic only in 39% These studies suggest that syncope in some HF patients may be an indica- tor of an end-stage cardiomyopathy associated with a poor prognosis.S7.2.1-11 In a substudy of DEFINITE, inducible sustained VT/VF was found in a minority of patients, but it was associated with appropriate ICD therapy.S7.2.1-14 Another study of electrophysiological testing in NICM found inducible VT/VF in 27.8% of patients, which was associated with future ICD events.S7.2.1-15 In a study of patients with NICM, cardiac mortality correlated with LVEF but not with inducibility on Based on these data, many experts are uncomfortable withhold- ing an ICD from patients with NICM who expe- rience syncope potentially due to a VA even if the electrophysiological study shows no inducible sustained VT. 3. Access to ICDs may be limited by financial, medi- cal, or personal considerations. In addition, not all patients at high risk of SCD meet ICD indica- tions, such as those with class IV HF without CRT possibility or with a life expectancy <1 year. 