Filling Gaps in Guidelines: BiV pacing, ICDs Get Appropriate-Use Criteria

March 04, 2013

WASHINGTON, DC — Where the evidence-based guidelines fall short for implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT), a new appropriate-use criteria (AUC) document picks up the slack [1].

Developed with the collaboration of nine medical societies and endorsed by a 10th, the document's core is 369 clinical scenarios based on gray areas in the guidelines and designed by the 10-member writing committee. Each scenario was then rated on a scale ranging from "appropriate" to "may be appropriate" to "rarely appropriate" by a larger "technical panel" that included some writing committee members plus other experts.

Many of the scenarios represent gaps in the guidelines or areas where there aren't or never will be a randomized trial.

"We put together the scenarios based on our own broad experience. They cover most of the scenarios [we encounter], though we all know in real practice there is a lot of individual variation among patients," writing committee cochair Dr Andrea M Russo (Cooper University Hospital, Camden, NJ) told heartwire .

The scenarios are grouped by ICDs for secondary prevention, ICDs for primary prevention, CRT, generator replacements, use of dual- vs single-chamber ICDs, and comorbidities.

"Many of the scenarios represent gaps in the guidelines or areas where there aren't or never will be a randomized trial," Russo said. "You really have to consider the individual, and that's what we tried to highlight."

The document was published online February 28, 2013 in the Journal of the American College of Cardiology and is scheduled for its March 26 print issue. It was produced jointly by the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance, and endorsed by the American Geriatrics Society.

The work of the writing committee and technical panel was conducted without commercial support. Russo disclosed consulting for Biotronik, Guidant/Boston Scientific, Medtronic, and St Jude Medical, and participating in research for Medtronic. Disclosures for the other committee and panel members are included in the report.