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Adopting evidence-based optimal implantable cardioverter-defibrillator programming: Overcoming the inertia

Published:October 28, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.10.029
      When implantable cardioverter-defibrillators (ICDs) first became available, they were indicated for those fortunate enough to have survived cardiac arrest. Compared to today’s ICDs, charge times were long, shock energies were low, and monophasic waveforms were used. The primary concern was delivering a shock rapidly to promptly restore coordinated electrical activity. When indications for ICDs expanded beyond secondary prevention, there was an increasing realization that while lifesaving therapy would benefit some, many patients would experience the downsides of living with an ICD. These negative impacts included both inappropriate shocks (shocks delivered when ventricular arrhythmia was not occurring) and unnecessary shocks (shocks where antitachycardia pacing may have been effective or when the ventricular arrhythmia would have self-terminated without therapy). The challenge then became how can we minimize those unneeded shocks without exposing patients to more syncope and while maintaining the aim of successfully restoring coordinated electrical activity when really needed?
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