Appropriate use of implantable cardioverter-defibrillators at a single academic center

In a new publication from Cardiovascular Innovations and Applications; DOI https://doi.org/10.15212/CVIA.2021.0005, Nikhil H. Shah, Steven J. Ross, Steve A. Noutong Njapo, Justin Merritt, Andrew Kolarich, Michael Kaufmann, William M. Miles, David E. Winchester, Thomas A. Burkart, and Matthew McKillop from UF Division of Cardiovascular Medicine, Gainesville, FL, USA, UVA Division of Cardiovascular Medicine, Charlottesville, VA, USA, The Johns Hopkins Hospital Department of Radiology, Baltimore, MD, USA, The Heart Center, Huntsville, AL, USA, Intermountain Medical Center, St. George, UT, USA and Carolina Cardiology Consultants, Greenville, SC, USA consider appropriate use of implantable cardioverter-defibrillators at a single academic center.

Implantable cardioverter-defibrillators (ICDs) can be life-saving devices, although they are expensive and may cause complications. In 2013, several professional societies published joint appropriate use criteria (AUC) assessing indications for ICD implantation. Data evaluating the clinical application of AUC are limited. Previous registry-based studies estimated that 22.5% of primary prevention ICD implantations were "non-evidence-based" implantations.

On the basis of AUC, the authors aimed to determine the prevalence of "rarely appropriate" ICD implantation at their institution for comparison with previous estimates by reviewing 286 patients who underwent ICD implantation between 2013 and 2016. Appropriateness of each ICD implantation was assessed by independent review and rated on the basis of AUC.

Of 286 ICD implantations, two independent reviewers found that 89.5% and 89.2%, respectively, were appropriate, 5.6% and 7.3% may be appropriate, and 1.8% and 2.1% were rarely appropriate. No AUC indication was found for 3.5% and 3.4% of ICD implantations, respectively. Secondary prevention ICD implantations were more likely rarely appropriate (2.6% vs. 1.2% and 3.6% vs. 1.1%) or unrated (6.0% vs. 1.2% and 2.7% vs. 0.6%). The reviewers found 3.5% and 3.4% of ICD implantations, respectively, were non-evidence-based implantations. The difference in rates between reviewers was not statistically significant.

Compared with prior reports, the prevalence of rarely appropriate ICD implantation was very low. The high appropriate use rate could be explained by the fact that AUC are based on current clinical practice. The AUC could benefit from additional secondary prevention indications. Most importantly, clinical judgement and individualized care should determine which patients receive ICDs irrespective of guidelines or criteria.

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Citation information: Better Than You Think--Appropriate Use of Implantable Cardioverter-Defibrillators at a Single Academic Center: A Retrospective Review, Nikhil H. Shah, Steven J. Ross, Steve A. Noutong Njapo, Justin Merritt, Andrew Kolarich, Michael Kaufmann, William M. Miles, David E. Winchester, Thomas A. Burkart, and Matthew McKillop, Cardiovasc. Innov. App., 2021,
https://doi.org/10.15212/CVIA.2021.0005

Keywords: Appropriate use; appropriate use criteria; implantable cardioverter-defibrillator

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