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For allocation of primary ICD-therapy, a possible lower limit of inclusion criteria—defining overly advanced heart failure—is less well investigated. Also, a multi-variable approach to stratification beyond ejection fraction (LVEF) appears warranted. We examined whether adding a selection limit of peak VO2 ≤ 14 ml/kg/min to LVEF ≤ 20% improves stratification. Furthermore, we sought to provide current survival data and a size-estimate for prospective trials based on real-life data for this high risk cohort. In our prospective clinical registry 1,926 patients with systolic CHF were recruited consecutively since 1994. Of these patients, 292 met the selection criteria described above. The mean age was 57.6 ± 9.5 years, 83% were male, 37% had ischemic cardiomyopathy and 28% received primary ICD-therapy. All cause mortality was considered as end point. Median follow-up was 45 (18–86) months. ICD was not a significant predictor of outcome either for the entire population, or grouped according to aetiology of CHF. Still, 3-year mortality was 15% (ICD-patients) Vs. 28% (non-ICD-patients); P = 0.05; under combination medical therapy. Inversely, in ICD-patients medical combination therapy conveyed a significant survival benefit ( P < 0.001). Consequently, the number-needed-to-treat was eight under combination therapy and the size estimate amounts to 300 patients for a prospective trial in this cohort. A cut-off of LVEF ≤ 20% and pVO2 ≤ 14 ml/kg/min could identify patients that do not draw a significant survival benefit from adjunct primary ICD-therapy. Our results indicate the need for a specific randomized trial in this cohort. The according mortality data and a size estimate are provided. [ABSTRACT FROM AUTHOR]