Societies release consensus statement on ICD programming, testing
Four societies released a consensus statement on optimal programming and testing for implantable cardioverter defibrillators.
“This document is a long overdue effort to provide analysis and guidance to the clinician as to how to make strategic programming choices in the implementation of ICD therapy,” Bruce L. Wilkoff, MD, FHRS, CCDS, chair of the writing committee, and colleagues wrote. “The four continental electrophysiology societies limited the discussion and recommendations to four areas for which there was sufficient consensus and data. ... However, there is an information gap of sufficient data filled with opinions and logical arguments.”
Bruce L. Wilkoff
The panelists representing the Heart Rhythm Society, the European Heart Rhythm Association, the Asia-Pacific Heart Rhythm Society and the Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia made recommendations in four areas: bradycardia mode and rate programming, tachycardia detection programming, tachycardia therapy programming and intraprocedural testing of defibrillation efficacy.
Under bradycardia mode and rate programming, Wilkoff, from Cleveland Clinic and the Cardiology Today Editorial Board, and colleagues issued two class I recommendations: that patients with an ICD and sinus node disease indicated for a bradycardia pacemaker may benefit from dual-chamber pacing to reduce risk for atrial fibrillation and stroke, avoid pacemaker syndrome and improve quality of life; and that patients with an ICD but no indication for bradycardia pacing should have their pacing parameters adjusted to minimize ventricular stimulation, which could improve survival and reduce hospitalization for HF. Both were designated level of evidence B-R.
Reduction of total shocks
The panel made many recommendations on tachycardia detection programming, two of which received a designation of class 1, level of evidence A. They wrote that for patients who have an ICD for primary prevention, programming of tachyarrhythmia detection duration criteria should require the tachycardia to continue for 6 to 12 seconds or for 30 intervals before determining that therapy should be administered. They also wrote that for those patients, the slowest tachycardia therapy zone limit should be programmed between 185 bpm and 200 bpm, also to prevent excessive therapy.
There were two class I, level of evidence A recommendations in tachycardia therapy programming. Wilkoff and colleagues wrote that all patients with structural heart disease and ICD therapy capable of antitachycardia pacing should have antitachycardia pacing therapy active for all ventricular tachyarrhythmia detection zones so that arrhythmias up to 230 bpm can be included to reduce total shocks. They also wrote that in that same population, antitachycardia pacing therapy should be programmed to deliver at least one attempt at therapy with a minimum of eight stimuli and 84% to 88% of the tachycardia cycle length, also to reduce total shocks.
In the category of intraprocedural testing of defibrillation efficacy, the panel recommended that defibrillation testing be performed in patients undergoing implantation of a subcutaneous ICD, and that defibrillation testing not be performed during implantation of a transvenous ICD in certain patients.
“This document is a beginning, necessary because there are now sufficient data to support recommendations that improve the safety, morbidity and mortality of patients with ICDs,” they wrote. – by Erik Swain
Disclosure: Wilkoff reports consulting for Boston Scientific and St. Jude Medical, holding equity in CardioMEMS and receiving royalty income from Medtronic. Please see the full statement for a list of the relevant financial disclosures of the other authors and reviewers.