2019 Focused Update on Optimal ICD Programming and Testing

Authors, Journal, Affiliations, Type, DOI

• Authors: Martin K. Stiles (Chair), Laurent Fauchier, Carlos A. Morillo, Bruce L. Wilkoff; document reviewers Boveda, Gold, Keegan, Kutyifa, Lau, McGuire, Mulpuru, Slotwiner, Uribe
• Journal: Europace 2019;21:1442–1443g (EHRA position paper; copublished in HeartRhythm and the Journal of Arrhythmia)
• Affiliations: Waikato Hospital (Hamilton, New Zealand); CHU Trousseau, Université François Rabelais (Tours, France); Libin Cardiovascular Institute of Alberta, University of Calgary (Canada); Cleveland Clinic (USA)
• Type: Expert consensus statement — focused update, with manufacturer-specific programming translations (Appendix B)
• DOI: 10.1093/europace/euz065

Overview

This focused update revises the 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on ICD programming and testing, retaining its 32 consensus recommendations but correcting manufacturer-specific translations that had produced adverse outcomes. It covers four clinical domains — bradycardia programming, tachycardia detection, tachycardia therapy and defibrillation testing — and translates each recommendation into concrete settings for Abbott, BIOTRONIK, Boston Scientific, Medtronic and MicroPort devices. The writing group explicitly privileges randomised trial and large-registry data over anecdotal reports, while stating that the recommendations do not replace individualised clinical judgement.

Keywords

Antitachycardia pacing; Bradycardia mode and rate; Defibrillation testing; Implantable cardioverter-defibrillator; Programming; Sudden cardiac death; Tachycardia detection; Tachycardia therapy; Ventricular tachycardia; Ventricular fibrillation

Key Takeaways

Purpose and method of the update

• The 2015 statement provided guidance on bradycardia programming, tachycardia detection, tachycardia therapy and defibrillation testing, graded by Class of Recommendation and Level of Evidence.
• Appendix B translated those recommendations into manufacturer-specific settings. Because the underlying data came from devices of individual manufacturers, some translations were approximations; adverse outcomes were subsequently reported in devices programmed to those Appendix B settings, prompting this review.
• The update's stated principle: randomised trials and large registry data should guide programming more than anecdotal evidence. The authors note an asymmetry in how harm is perceived — patients spared unnecessary therapy are unaware of it, whereas device failures are recorded in detail.
• Recommendations are explicitly not a substitute for the treating physician's judgement exercised through shared decision-making.

Bradycardia programming — the common template

• Single-chamber: VVI at 40 bpm across all manufacturers.
• Dual-chamber: DDD, with manufacturer-specific algorithms to minimise unnecessary ventricular pacing — Managed Ventricular Pacing (Medtronic), Ventricular Intrinsic Preference (Abbott), IRS Plus/OPT or Vp Suppression (BIOTRONIK), RYTHMIQ or AV Search+ (Boston Scientific), SafeR (MicroPort).
• CRT: DDD ± rate response, with device-specific CRT optimisation (e.g. Adaptive BiV & LV in Medtronic devices; SyncAV in Abbott; Smart Delay in Boston Scientific; weekly AV/VV optimisation in MicroPort).

Tachycardia detection — two strategies for patients without a VT history

• Delayed-therapy strategy: high detection rates with long detection intervals (e.g. Medtronic VF 30/40 intervals at 188 bpm; Abbott VF 30 intervals at 240/250 bpm; BIOTRONIK VF 30/40 at 231 bpm; Boston Scientific VF 8/10 intervals plus a 5-second duration at 250 bpm).
• High-rate strategy: a single high-rate zone (e.g. Boston Scientific option 2 — VF 8/10 intervals plus 2.5-second duration at 200 bpm; MicroPort VF >255 bpm with 20 cycles + 6/8 majority).
• In patients with a known VT cycle length, VT therapy is programmed at 10–20 bpm below the clinical VT rate (or a monitor zone at the clinician's discretion). FVT zones are switched OFF in Medtronic and Abbott translations, because ATP during charging in the VF zone provides equivalent functionality and allows tiered ATP.
• A monitor zone is optional and left to clinician discretion in every manufacturer's translation.

Tachycardia therapy — ATP first, shocks as backup

• VF: ATP during/before charging where available, followed by full-output shocks (unless DFT-guided).
• VT: at least one ATP burst of 8 pulses at ~88% of the VT cycle length with a 10 ms scan decrement; subsequent bursts/shocks for failed ATP.
• ATP is favoured over shocks wherever a tier is programmable, based on the trial evidence that ATP terminates most fast VT without shock.
• SVT discriminators are recommended in single- and dual-chamber devices — wavelet/far-field morphology, interval stability, onset, PR logic/SMART/Parad/RhythmID depending on manufacturer — with a SVT upper limit around 230 bpm, above which discrimination is not applied. Discriminators are not required in complete heart block.
• Oversensing rejection features (lead-integrity alerts, T-wave oversensing filters, RV lead-noise discrimination) are switched ON where available.

Defibrillation testing

• The document retains the 2015 position on DFT testing; the manufacturer tables specify shocks as "full output unless DFT guided", meaning the update does not mandate routine testing but preserves it as a clinical option.

Manufacturer-specific examples (Appendix B)

• Medtronic: VF 30/40 at 188 bpm; VT OFF when no VT history; VT 24 intervals at 10–20 bpm below VT rate when known; ATP Rx1 ≥1 burst at 88% VT CL with 10 ms decrement; Wavelet + PR Logic; SVT limit 260 ms (230 bpm).
• Abbott: VF 30 intervals at 240/250 bpm; VT2 30 intervals at 187 bpm; ATP while charging at 85% VT CL; far-field morphology ON (90%, 3 of 10); SVT limit 230 bpm.
• BIOTRONIK: VF 30/40 at 231 bpm; VT2 30 intervals at 188 bpm; ATP one-shot at 88% CL; MorphMatch ON; SMART in dual chamber.
• Boston Scientific: VF 8/10 intervals + 5 s at 250 bpm (delayed option) or 8/10 + 2.5 s at 200 bpm (high-rate option); ATP-1 scan ≥1 burst at 84% coupling interval; RhythmID; S-ICD shock zone ≥230 bpm and conditional zone ≥200 bpm.
• MicroPort: VF >255 bpm (20 cycles, 6/8 majority); FVT 230 bpm; VT 185 bpm; ATP burst/scan at 85% with 8 beats; PARAD+ discrimination.

Limitations of the document

• Consensus, not a systematic review or meta-analysis. Recommendations are graded expert opinion synthesising trials and registries; no new primary data are presented.
• The converted raw text contains only the introduction and Appendix B manufacturer tables. The 32 numbered recommendations, their Class/Level of Evidence, the rationale text, and the supporting references are present in the original document but not extractable from this conversion — the tables are supplied as images.
• Manufacturer translations are explicitly approximate, not the nominal settings of any device nor the exact programming tested in trials. The document itself warns they are "not applicable in all circumstances".
• Device generations change faster than consensus documents. Settings reference specific legacy platforms (e.g. Medtronic FVT zone, Abbott SyncAV, MicroPort PARAD+), and some may not map onto current firmware.
• No patient-level evidence for the revised translations. The update corrects settings reported to cause harm, but does not report outcome data confirming the revised values are safer.
• The document predates the widespread adoption of conduction-system pacing, leadless pacemakers and extravascular ICDs, and does not address programming for those systems.

Key Concepts Mentioned

• concepts/ICD-Programming — the concept this document defines; detection zones, ATP, discriminators, oversensing rejection
• entities/ICD — the device being programmed
• concepts/Antiarrhythmic-Drugs — pharmacotherapy that interacts with device detection (rate slowing, proarrhythmia)
• concepts/Sudden-Cardiac-Death — the outcome ICD programming aims to prevent
• entities/Heart-Failure — CRT programming is included in the same framework

Key Entities Mentioned

• Heart Rhythm Society (HRS) — lead society
• European Heart Rhythm Association (EHRA), Asia Pacific Heart Rhythm Society (APHRS), Latin American Heart Rhythm Society (LAHRS) — partner societies
• Abbott, BIOTRONIK, Boston Scientific, Medtronic, MicroPort CRM — device manufacturers whose settings are translated
• Mirowski et al. — developers of the ICD (historical context in the parent statement)

Wiki Pages Updated

• Created: wiki/sources/icd-programming-hrs-2019.md
• Created: wiki/concepts/ICD-Programming.md
• Updated: wiki/entities/ICD.md
• Updated: wiki/sourceindex.md
• Updated: wiki/wikiindex.md
• Updated: Arrhythmia-index.md
• Updated: log.md