Outcomes Following Standardized Implantable Cardioverter-defibrillator Reprogramming

Multiple randomized controlled trials have demonstrated that programming implantable cardioverter-defibrillators (ICDs) with longer detection intervals and higher detection rates results in significant reductions in the delivery of inappropriate therapy without increasing the number of adverse events. Despite these findings, however, implementation of this evidence-based programming, particularly in previously implanted ICDs, remains inconsistent throughout the United States, with significant provider-dependent variability. We developed an institutionally standardized ICD reprogramming protocol for primary prevention ICDs utilizing high detection rates and long detection intervals, then prospectively evaluated outcomes in patients programmed with this protocol compared to a historical cohort. A total of 193 patients with primary prevention ICDs underwent standardized reprogramming and were monitored over a 1-year period. A historical cohort of 254 patients with ICD with non-standardized programming implanted prior to initiation of the standardized protocol were used as a comparison group. The primary outcomes were rates of appropriate or inappropriate ICD therapy. Secondary outcomes were rates of syncope, emergency department (ED) or urgent care (UC) visits, hospitalization, and death. All patients seen in the device clinic who qualified for device standardization were reprogrammed according to the previously developed evidence-based, institutionally standardized protocol. Patients who underwent standardized reprogramming had a lower prevalence of inappropriate therapy compared to the historical cohort (0% vs. 2.4%, P = .04); the prevalence of appropriate therapy was also lower in the reprogrammed group (4.1% vs. 7.1%) but not to a statistically significant degree (P = .19). There was a lower prevalence of syncope in the reprogrammed group (0% vs. 2.8%, P = .02). No significant difference in the prevalence of ED or UC utilization (37.8% vs. 33.9%, P = .39) or mortality (4.1% vs. 3.5%, P = .74) was found. Prospective standardized reprogramming of new and previously implanted primary prevention ICDs with high-rate detection and longer detection intervals may be an effective method to obtain high adherence to evidence-based reprogramming and reduce rates of inappropriate device therapies without a significant impact on appropriate therapies or mortality.