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

Abstract

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.

Keywords

• guideline adherence
• guidelines
• implantable cardioverter‐defibrillator
• programming
• remote monitoring