Longer detection times reduce ICD shocks without compromising safety – ADVANCE III Trial

Longer detection times reduce ICD shocks without compromising safety – ADVANCE III Trial

Longer detection times reduce ICD shocks without compromising safety: Even though implantable cardioverter defibrillator (ICD) is a life saving device, getting the shock is one of the most unpleasant aspects of ICDs from the recipient point of view. There are even recipients asking for explantation after getting fed up of shocks, more so with inappropriate shocks. In this setting, Avoid Delivering Therapies for Nonsustained Arrhythmias in ICD Patients III (ADVANCE III) Trial [1] evaluated whether avoiding therapies for potentially self limited episodes of ventricular tachycardia can reduce the number of shocks. The study had 1902 patients, of which 477 had secondary prevention indications for ICD. 248 patients were randomized to a long detection setting (30 or 40 intervals) and 229 to the nominal setting (18 of 24 intervals) for ventricular arrhythmias with cycle length of 320 ms or less. The study documented that long detection interval could reduce the number of shocks in both primary and secondary prevention groups without compromising on safety. Antitachycardia pacing was given during device charging as usual. 37% ICD devices in this study were single chamber, 47% dual chamber and 16% triple chamber (biventricular ICD or cardiac resynchronization therapy defibrillator, CRT-D).

Data from ADVANCE III trial for single chamber (VVI) ICDs has been published separately [2]. Of the 545 subjects, 25% had atrial fibrillation. 32% were for secondary prevention and 68% had ischemic etiology. Randomization was either to a long detection time of 30 of 40 intervals or standard programming of 18 of 24 intervals, based on device type, history of atrial fibrillation and indication for implantation. In both arms, antitachycardia pacing during charging was programmed for episodes with cycle lengths 320 to 200 ms and shock only for cycle length less than 200 ms. It was shown that programming long detection interval significantly reduced appropriate therapies, shocks and all-cause mortality.

In MADIT-RIT (Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy), those who had the first episode of ventricular tachycardia (VT) were reprogrammed into three arms [3]. Arm A was conventional therapy, with VT zone at rate 170 beats/min or more, arm B of high rate therapy with VT zone at 200 beats/min or more and arm C with 60 seconds delay before therapy for 170 beats/min or more.  At 15 months follow up, the cumulative probability of inappropriate ICD therapy was significantly lower in arm B/C, compared to A. Those programmed to B/C after the occurrence of a ventricular tachycardia had 71% reduction in the risk of inappropriate ICD therapies and 43% reduction of appropriate therapies compared to A. The risk of adverse cardiovascular events comprising heart failure hospitalization, syncope or death was similar between those programmed to novel ICD settings and those programmed to conventional settings.

References

  1. Axel Kloppe, Alessandro Proclemer, Angel Arenal, Maurizio Lunati, José Bautista Martìnez Ferrer, Ahmad Hersi, Marcin Gulaj, Maurits C E F Wijffels, Elisabetta Santi, Laura Manotta, Lorenza Mangoni, Maurizio Gasparini. Efficacy of Long Detection Interval Implantable Cardioverter-Defibrillator Settings in Secondary Prevention Population. Circulation. 2014; 130: 308-314.
  2. Gasparini M, Lunati MG, Proclemer A, Arenal A, Kloppe A, Martínez Ferrer JB, Hersi AS, Gulaj M, Wijffels MCE, Santi E, Manotta L, Varma N. Long Detection Programming in Single-Chamber Defibrillators Reduces Unnecessary Therapies and Mortality: The ADVANCE III Trial. JACC Clin Electrophysiol. 2017 Nov;3(11):1275-1282.
  3. Aktas MK, Bennett AL, Younis A, Kutyifa V, Polonsky B, McNitt S, Zareba W, Rosero S, Goldenberg I. Implantable cardioverter-defibrillator programming after first occurrence of ventricular tachycardia in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT). Heart Rhythm O2. 2020 May 11;1(2):77-82.