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Updated: Feb 1, 2026
A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and Ease of Implantation
Published on: February 28, 2012
A Population-Based Study of Adherence to Guideline Recommendations and Appropriate-Use Criteria for Implantable
Rochelle Bernier1, Mohammed Al-Shehri2, Satish R Raj2
1Mazankowski Alberta Heart Institute, University of Alberta, Division of Cardiology, Edmonton, Alberta, Canada.
Insights
Physician adherence to implantable cardioverter defibrillator (ICD) guidelines is high, with a quality improvement process ensuring appropriate use. Specialist evaluation and peer review significantly enhance adherence to ICD therapy recommendations.
Area of Science:
- Cardiology
- Medical Device Technology
- Health Services Research
Background:
- Physician adherence to implantable cardioverter defibrillator (ICD) guidelines is not well-studied.
- Application of appropriate-use criteria (AUC) for ICD therapy in clinical practice lacks evaluation.
- Quality improvement initiatives are crucial for optimizing device therapy adherence.
Purpose of the Study:
- To evaluate physician adherence to ICD therapy recommendations and appropriate-use criteria (AUC).
- To identify reasons for nonadherence to guideline recommendations and AUC for ICD implantation.
- To assess the impact of a quality improvement process on ICD therapy appropriateness.
Main Methods:
- A population-based review of 1,300 ICD procedures in Alberta, Canada (January 2015 - December 2016).
- Classification of implants based on 2008 ACC/AHA/HRS ICD guidelines, 2013 CCS CRT guidelines, and 2013 AUC.
- Analysis of patient demographics, ejection fraction, and reasons for nonadherence.
Main Results:
- Less than 1% of all ICD implants were discordant with ACC/AHA/HRS recommendations.
- 10% of cardiac resynchronization therapy (CRT) implants were inconsistent with CCS recommendations.
- 92% of ICD implants were deemed appropriate according to AUC, with 4% nonadherence attributed to absence of criteria.
Conclusions:
- A structured process involving specialist evaluation, eligibility reminders, and peer-review consensus can significantly improve adherence to ICD guidelines and AUC.
- The quality improvement initiative demonstrated high adherence rates for ICD therapy.
- Further research into specific criteria for AUC classification may enhance adherence further.
Abstract:
Studies evaluating physician adherence to guideline recommendations for implantable cardioverter defibrillator (ICD) therapy are sparse, and none exist for the application of appropriate-use criteria (AUC) in clinical practice. As part of a quality improvement initiative, a review of all ICD procedures was performed from January 1, 2015 to December 31, 2016 in Alberta, Canada, to evaluate the proportion of patients receiving appropriate ICD therapy and to identify reasons for nonadherence. Our device-implant process involves an electrophysiologist or implanting cardiologist evaluation, reminders of ICD eligibility criteria on the device requisition, and peer-review consensus. Implants were classified according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) ICD guidelines, 2013 Canadian Cardiovascular Society (CCS) Cardiac Resynchronization Therapy (CRT) guidelines, and 2013 AUC. There were 1,300 ICD procedures performed, and the mean age was 63.8 ± 12.9 years; 79% were male; the mean ejection fraction was 0.32 ± 0.13, and 69% were for primary prevention. Among all implants, < 1% were discordant with American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) recommendations. Among CRT implants, 10% were inconsistent with Canadian Cardiovascular Society (CCS) recommendations. According to AUC, 92% of implants were appropriate. Reasons for nonadherence to ACC/AHA/HRS recommendations included QRS width < 120 msec (n = 3), LVEF > 0.35 (n = 2) and recent myocardial infarction (MI) (n = 1). The most common reason for nonadherence to AUC was the absence of criteria for classification (n = 57, 4%). In this population-based study, we found that a process of specialist evaluation, eligibility reminders on device forms, and peer-review consensus may improve adherence to guideline recommendations and AUC for ICD therapy.
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