We Have Come a Long Way on the Appropriateness of Implantable Cardioverter-Defibrillator Implantation: What Have We Learned from This Journey?

Randomized clinical trials have proven the survival benefit of implantable cardioverter defibrillators (ICDs) in different patient populations. 1) Antiarrhythmics Versus Implantable Defibrillators (AVID) InvestigatorsA comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997; 337: 1576-1583 Google Scholar , 2) Bardy G.H. Lee K.L. Mark D.B. et al. Sudden Cardiac Death in Heart Failure Trial I. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005; 352: 225-237 Google Scholar , 3) Moss A.J. Zareba W. Hall W.J. et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002; 346: 877-883 Google Scholar Evidence generated by these trials has informed professional guidelines on ICDs for many years. 4) Al-Khatib S.M. Stevenson W.G. Ackerman M.J. et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2018; 138: e272-e391 Google Scholar , 5) Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. Circulation. 2008; 117: e350-e408 Google Scholar , 6) Tracy C.M. Epstein A.E. Darbar D. et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. 2013; 61: e6-e75 Google Scholar The most recent AHA/ACC/HRS guideline document on the prevention of sudden cardiac death (SCD) clearly acknowledged that while the guideline is intended to define practices that prioritize the needs of patients, it does so for most, but not all, situations, and it, therefore, should not replace clinical judgment. 4) Al-Khatib S.M. Stevenson W.G. Ackerman M.J. et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2018; 138: e272-e391 Google Scholar Indeed, it is impossible for any guideline document to consider or anticipate all potential clinical scenarios, and clinicians have to understand the collective available evidence and consider the nuances of each patient's clinical presentation to formulate the best clinical recommendations. Recognizing that guidelines cannot possibly cover all potential clinical scenarios, professional societies published appropriate use criteria (AUC) for ICDs and cardiac resynchronization therapy (CRT) in 2013 to provide additional guidance regarding the use of these devices for a large number of clinical scenarios beyond what the 2008 and 2012 focused update of the guideline had offered. 5) Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. Circulation. 2008; 117: e350-e408 Google Scholar , 6) Tracy C.M. Epstein A.E. Darbar D. et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. J Am Coll Cardiol. 2013; 61: e6-e75 Google Scholar , 7) Russo A.M. Stainback R.F. Bailey S.R. et al. ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy. J Am Coll Cardiol. 2013; 61: 1318-1368 Google Scholar These AUC were intended to be used in conjunction with the guidelines. Developing AUC is quite laborious and is time and resource consuming; therefore, examining how these AUC are being implemented in relation to quality improvement efforts on ICD and CRT-D implants is important. Appropriateness of Internal Cardioverter-Defibrillator Device Implants in the United StatesHeart RhythmPreviewThe appropriate use criteria (AUC) are a diverse group of indications aimed to better evaluate the benefits of ICD and CRT therapy. Full-Text PDF