Contemporary adherence to therapy restrictive implantable cardioverter-defibrillator programming: a cross-sectional analysis

Implantable cardioverter defibrillators (ICDs) save lives by detecting and terminating life-threatening arrhythmias with rapid pacing or high-energy shocks. Several large-scale randomised trials have definitively demonstrated that programming ICDs to restrict therapies ("therapy-restrictive programming", or TRP) to only the most severe ventricular arrhythmias reduces harmful and distressing inappropriate and unnecessary therapies, which substantially reduces mortality compared to therapy-permissive programming. Although firmly established in guidelines, it is not known if real-world patients receive evidence-based ICD programming.

We utilised a large European remote-monitoring device database to explore adherence to therapy restrictive programming across multiple manufacturers.

The study population comprised all patients with ICDs implanted from 2018-2022, whose devices were remote monitored in a commercially administered database with linkage to electronic health records for clinical information. Patients with primary prevention ICDs implanted for heart failure with reduced ejection fraction were eligible. Therapy adherence standards were harmonised across manufacturers.

The primary outcome, proportion of all devices non-adherent to TRP, was 68.7% (1246/1815). 34.8% of devices permitted ICD therapies with a minimum duration of ≤180bpm. 2.4% permitted therapies with a minimum duration of ≤160bpm. For manufacturers with probabilistic counters the proportion of these devices non-adherent to TRP was 48.4% (357/738).

Over two thirds of contemporary ICD recipients in a large real-world remote monitoring database did not have guideline-adherent programming, which is a well-established, life-extending standard. More intense focus on implementation pathways for therapy-restrictive programming are needed.

Baseline demographics