Audit of Implantable Cardioverter Defibrillator (ICD)

shocks in 365 patients at Aberdeen Royal Infirmary

Chris Llewellyn, Vui Yung Chieng, Jonathan Affolter Cardiology Department,
Aberdeen Royal Infirmary
Graph 2

Clinical Audit

Background
The Implantable Cardioverter Defibrillator (ICD) is a proven life
saving therapy for patients at risk of Sudden Cardiac Death
(SCD). The ICD is a small electronic device that is implanted
under the skin with one or more leads connected to the heart.
The device is capable of monitoring the hearts activity
delivering anti-tachycardia pacing therapy (ATP) and high
energy (850V) shocks for the treatment of life threatening
ventricular arrhythmias.
ICD shocks although life saving are painful, psychologically
damaging, pro-arrhythmic, can result in deterioration in heart
failure symptoms, increase mortality and shocks also deplete
the ICD battery. The goal of the ICD is to deliver only deliver
therapy to treat only arrhythmias that would lead to death. The
ICD can also deliver therapy for inappropriate reasons such as
atrial fibrillation, sinus tachycardia, Supraventricular
tachycardia, or external noise.

Literature review

Shock
(n=56)

No shock
(n=308)

All patients
n (%)

137 (44.5%)
88 (28.6%)
6 (1.9%)
77 (25.0%)

167 (45.9%)
107 (29.4%)
8 (2.2%)
82 (22.5%)
0.01b

17 (30.4%)
18 (32.1%)
12 (21.4%)
9 (16.1%)

166 (53.9%)
55 (17.9%)
47 (15.3%)
40 (13.0%)

183 (50.3%)
73 (20.1%)
59 (16.2%)
49 (13.4%)

Time to first shock

Survival probability (%)

This review recommended implementing a delay to the

delivery of first ICD therapy in conjunction with optimal
discriminators, high cut off rates for discrimination, and high
rate ATP.

20

16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%

appropriate shock

ARI
11.2%

Inappropriate shock

3.3%

Control

PREPARE 12 Months
5.4%
9.4%
3.6%

7.5%

Treatment

Control

RELEVANT 14 Months
4.3%
5.6%
1.8%

5.0%

Treatment

Control

PROVIDE 24 Months
4.9%
4.9%
5.4%

13.8%

Treatment

Control

MADIT-RIT 17 Months
4.0%
5.0%
3.0%

6.0%

Inappropriate therapy
Appropriate therapy

Graph 3
Inappropriate shocks at ARI

11.23%

10

4.50%

Author

Year

3.29%

No of patients

4.00%

Inappropriate shocks

3.50%

ADVANCE III

MADIT-RIT
PROVIDE
RELEVANT

Gasparini et al

Moss et al
Saeed et al
Gasparini et al

2013

2012
2012
2009

1902

1500
1670
321

3.00%

10

15

20

25

30

35

Months

Wilkoff et al

2008

691

2.50%
2.00%

References

1.50%

Gasparini, M., Menozzi, C., Proclemer, A., Landolina, M., Iacopino, S., Carboni, A., ... & Boriani, G. (2009). A simplified biventricular defibrillator with fixed long detection intervals reduces implantable
cardioverter defibrillator (ICD) interventions and heart failure hospitalizations in patients with non-ischaemic cardiomyopathy implanted for primary prevention: the RELEVANT [Role of long dEtection window
programming in patients with LEft VentriculAr dysfunction, Non-ischemic eTiology in primary prevention treated with a biventricular ICD] study. European heart journal, 30(22), 2758-2767.

1.00%

Gasparini, M., Proclemer, A., Klersy, C., Kloppe, A., Lunati, M., Ferrer, J. B. M., ... & Arenal, A. (2013). Effect of Long-Detection Interval vs Standard-Detection Interval for Implantable Cardioverter-Defibrillators
on Antitachycardia Pacing and Shock DeliveryThe ADVANCE III Randomized Clinical TrialLong-and Standard-Detection Intervals for ICDs. JAMA, 309(18), 1903-1911.

0.50%

Moss, A. J., Schuger, C., Beck, C. A., Brown, M. W., Cannom, D. S., Daubert, J. P., ... & Zareba, W. (2012). Reduction in inappropriate therapy and mortality through ICD programming. New England Journal
of Medicine, 367(24), 2275-2283.

0.00%
Year 2011

Wilkoff, B. L., Williamson, B. D., Stern, R. S., Moore, S. L., Lu, F., Lee, S. W., ... & Holloman, K. K. (2008). Strategic Programming of Detection and Therapy Parameters in Implantable CardioverterDefibrillators Reduces Shocks in Primary Prevention PatientsResults From the PREPARE (Primary Prevention Parameters Evaluation) Study. Journal of the American College of Cardiology, 52(7), 541-550.

PREPARE

Treatment

Control

ADVANCE III 12 Months

6.7%
7.0%
2.7%

4.7%

This review has significantly altered programming practice

within the ARI cardiac rhythm management (CRM) in the
period since this review. This change in programming practice
has resulted in a significant reduction in inappropriate shocks
over a 4 year period (Graph 3). This reduction in shocks will
translate into a reduction in mortality and heart failure
hospitalizations without any increase in syncopal events or
negative impact on the patient.

Table 1 Studies reviewed

Study

Treatment

The ICD has the ability to prolong the life of the patient by
significantly reducing their risk of sudden cardiac death but
the trials reviewed show that delaying the delivery of therapy
can reduce the morbidity and mortality associated with ICD
therapy.

value
0.02b

30 (53.6%)
19 (33.9%)
2 (3.6%)
5 (8.9%)

18.0%

Discussion

Table 3: Defibrillator type and manufacturer (n=364)

30

The literature for delaying the delivery of first ICD therapy was
reviewed with specific emphasis on the reduction of
inappropriate and unnecessary ICD shocks, and patient safety.
The review looked at 5 prospective clinical trials (Table 1)

appropriate shock

20.0%

An audit was performed of 365 ICD patients at followed up at

Aberdeen Royal Infirmary reviewing patient demographics,
device settings and shocks delivered. The audit covered a 34
month period since the implementation of the review
recommendations from January 2012 until October 2014.
This data was compared to published research for the number
of appropriate and inappropriate shocks received.

Defibrillator type
ICD-VVI
ICD-DDD
CRT-VVI
CRT-DDD
Defibrillator manufacturer
Medtronic Inc.
St. Jude Medical Inc.
Boston Inc.
Biotronik Inc.

Inappropriate shock

Saeed, M., Styperek, R., Polosajian, L,. Khan, A., Hanna, I., Alonso, J., Robotis, D., Neason, C., & Saberi, L. (2012) Programming Implantable Cardioverter Defibrillators to Prolong Time to First Shock
Available from https://clinical.sjm.com/~/media/clinical-discoveries/CRM/new%20resources/data-presentations/PROVIDE%20Results%20-%20HRS%202012_7232012.ashx .

4.20%

Year 2012

1.60%

Year 2013

Year 2014

1.50%

0.60%