Trends in implantable cardioverter-defibrillator programming practices and its impact on therapies: Insights from a North American Remote Monitoring Registry 2007–2018

BACKGROUND: Recent evidence has revealed the utility of prolonged arrhythmia detection duration and increased rate cutoff to reduce implantable cardioverter-defibrillator (ICD) therapies. Data on real-world trends in ICD programming and its impact on outcomes are limited. OBJECTIVE: The purpose of this study was to evaluate trends in ICD programming and its impact on ICD therapy using a large remote monitoring database. METHODS: A retrospective analysis of patients with ICD implanted from 2007 to 2018 was conducted using the de-identified Medtronic CareLink database. Data on ICD programming (number of intervals to detection [NID] and therapy rate cutoff) and delivered ICD therapies were collected. RESULTS: Among 210,810 patients, the proportion programmed to a rate cutoff of >= 188 beats/min increased from 41% to 49% and an NID of >= 30/40 increased from 17% to 67% before May 2013 vs after February 2016. Programming to a rate cutoff of >= 188 beats/min, a ventricular fibrillation (VF) NID of >= 30/40, or a combined rate cutoff of >= 188 beats/min and VF NID of >= 30/40 were associated with reductions in ICD therapy. The largest reductions in ICD therapy occurred when the combination of rate cutoff >= 188 beats/min and VF NID >= 30/40 was programmed (antitachycardia pacing: hazard ratio [HR] 0.35; 95% confidence interval [CI] 0.34-0.36; P < .001; shocks: HR 0.67; 95% CI 0.65-0.69; P < .001; and antitachycardia pacing/shocks: HR 0.43; 95% CI 0.42-0.44; P < .001). CONCLUSION: Despite evidence supporting the use of prolonged detection duration and high rate cutoff, implementation of shock reduction programming strategies in real-world clinical practice has been modest. The use of evidence-based ICD programming is associated with reduced ICD shocks over long-term follow-up.