Primary prevention programming for defibrillators: need for a device clinic-based intervention

Excerpt

The advent of prophylactic or primary prevention implantation of implantable cardioverter-defibrillator (ICD) devices for patients with advanced cardiomyopathy has significant expanded indications for ICD implants, based on several randomized controlled trials that demonstrated a survival benefit, notably the Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) trials [1]. Subsequent recognition of the adverse effects of ICD shocks led to the increased use of anti-tachycardia pacing (ATP) in lieu of defibrillation therapy, based on randomized controlled data from the PainFREE Rx II trial [2]. Furthermore, to prevent adverse effects of excessive or inappropriate ICD therapies for ventricular and non-ventricular arrhythmias, strategic programming (detection and treatment of only fast, sustained ventricular tachycardia with initial ATP, followed by high-output ICD shock) was evaluated in the Primary Prevention Parameters Evaluation (PREPARE) study [3]. The favorable findings from this observational study eventually led to the design of the Multicenter Automatic Defibrillator Implantation Trial–Reduce Inappropriate Therapy (MADIT-RIT) study [4] and other studies to minimize inappropriate ICD therapies and mortality [5]. Based on this evidence, the Heart Rhythm Society (HRS) and other electrophysiology (EP) societies strongly recommend appropriate primary prevention programming that is manufacturer specific [6]. Despite this recommendation, uptake in the EP community and device clinics appears to be low. …