Effect of Long-Detection Interval vs Standard Detection Interval for Implantable Cardioverter-Defibrillators on Antitachycardia Pacing and Shock Delivery: The ADVANCE III Randomized Clinical Trial

May 09, 2013
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Authors:
Gasparini M, Proclemer A, Klersy C, et al.
Citation:
JAMA 2013;309:1903-1911.
Summary By:
Fred Morady, MD, FACC

Study Questions:

Can unnecessary implantable cardioverter-defibrillator (ICD) therapies be avoided by increasing the number of intervals for detecting ventricular tachycardia (VT)?

Methods:

In the ADVANCE III (Avoid Delivering Therapies for Nonsustained Arrhythmias in ICD Patients) prospective clinical trial, 1,902 patients (mean age 65 years) with a cardiomyopathy (mean ejection fraction 30%) who received an ICD for primary or secondary prevention of sudden cardiac death randomly were assigned to either standard-detection intervals (18 of 24 intervals, n = 954) or long-detection intervals (30 of 40 intervals, n = 948). The primary endpoint was the number of ICD therapies delivered during a median follow-up of 12 months.

Results:

The ICD therapy rate was significantly lower in the long-detection group (42 therapies per 100 patient-years) than in the standard-detection group (67 therapies per 100 patient-years). The frequency of appropriate ICD shocks did not differ between the two groups, but the frequency of inappropriate shocks was 45% lower in the long-detection group. The hospitalization rate was 19% lower in the long-detection group. There were no significant differences in the rate of syncope or in mortality rate between the two groups.

Conclusions:

The investigators concluded that in patients with an ICD, an increase in the number of intervals needed to detect VT from 18 of 24 to 30 of 40 is associated with a reduction in the number of unnecessary ICD therapies.

Perspective:

This trial confirms the results of the MADIT-RIT study in a larger number of patients. Increasing the number of intervals required for detection of VT minimizes unnecessary therapies by allowing more time for spontaneous termination of nonsustained VT. A larger number of intervals also allows for more accurate detection of supraventricular tachycardias, thereby minimizing inappropriate shocks.

Keywords: Tachycardia, Supraventricular, Tachycardia, Ventricular, Secondary Prevention, Cardiomyopathies, Hospitalization, Death, Sudden, Cardiac, Defibrillators, Implantable


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