Recommendations for post-implant monitoring of patients with cardiovascular implantable electronic devices: where do we stand today?

How Well Do Results From Randomized Clinical Trials and/or Recommendations for Implantable Cardioverter-Defibrillator Programming Diffuse Into Clinical Practice?Translation Assessed in a National Cohort of Patients With Implantable Cardioverter-Defibrillators ( ALTITUDE )

Background Inappropriate implantable cardioverter-defibrillator programming can be detrimental. Whether trials/recommendations informing best implantable cardioverter-defibrillator programming (high-rate cutoff and/or extended duration of detection) influence practice is unknown. Methods and Results We measured reaction to publication of MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy; 2012) and the Consensus Statement (2015) providing generic programming parameters, in a national cohort of implantable cardioverter-defibrillator recipients, using the ALTITUDE database (Boston Scientific). Yearly changes in programmed parameters to either trial-specified or class 1 recommended parameters (≥185 beats per minute or delay ≥6 seconds) were assessed in parallel. From 2008 to 2017, 232 982 patients (aged 67±13 years; 28% women) were analyzed. Prevalence of MADIT- RIT -specific settings before publication was <1%, increasing to 13.6% in the year following. Thereafter, this increased by <6% over 5 years. Among preexisting implants (91 171), most patients (58 739 [64.4%]) underwent at least 1 in-person device reprogramming after trial publication, but <2% were reprogrammed to MADIT - RIT settings. Notably, prevalence of programming to ≥185 beats per minute or delay ≥6 seconds was increased by MADIT - RIT (57.4% in 2013 versus 40.2% at baseline), but the following publication of recommendations had minor incremental effect (73.2% in 2016 versus 70.8% in 2015). High-rate cutoff programming was favored almost 2-fold compared with extended duration throughout the test period. Practice changes demonstrated large interhospital and interstate variations. Conclusions Trial publication had an immediate effect during 1 year postpublication, but absolute penetration was low, and amplified little with time. Consensus recommendations had a negligible effect. However, generic programming was exercised more widely, and increased after trial publication, but not following recommendations.

Role of Surface Electrocardiograms in Patients with Cardiac Implantable Electronic Devices

Surface electrocardiograms, both resting 12-lead electrocardiographs and ambulatory electrocardiograph monitoring, play an essential role in establishing indications for cardiac implantable electronic devices (pacemakers, cardiac implantable defibrillators, and cardiac resynchronization therapies), and in the evaluation of patients already implanted. Current devices have prolonged memory capabilities (defined as Holter functions) and remote monitoring functions, to evaluate the electrical properties and the automatic detection of arrhythmias. Nonetheless, surface electrocardiography remains the critical tool to detect device malfunction, evaluate programming and function, verify the automatic arrhythmia analysis and the delivered electric therapy, and prevent inappropriate intervention.

2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry

Ambulatory ECG (AECG) is very commonly employed in a variety of clinical contexts to detect cardiac arrhythmias and/or arrhythmia patterns which are not readily obtained from the standard ECG. Accurate and timely characterization of arrhythmias is crucial to direct therapies that can have an important impact on diagnosis, prognosis or patient symptom status. The rhythm information derived from the large variety of AECG recording systems can often lead to appropriate and patient-specific medical and interventional management. The details in this document provide background and framework from which to apply AECG techniques in clinical practice, as well as clinical research.