Among patients undergoing first-time ICD implantation without a pacing indication between 2010 and 2018, the use of a dual-chamber device decreased, according to a study using data from ACC’s EP Device Implant Registry and published March 22 in JAMA Network Open. Additionally, the study found that institutional variability in the use of atrial leads persists, which the researchers say suggests differences in individual or institutional cultures of real-world practice and opportunity to reduce this low-value practice.

The multicenter cross-sectional study, conducted by Ryan T. Borne, MD, FACC, et al., included 266,182 patients undergoing initial implantation of a single- (n=134,925) or dual-chamber (n=131,257) transvenous ICD without a bradycardia pacing indication, class I or II CRT indication, or history of atrial fibrillation or atrial flutter.

The use of dual-chamber ICDs decreased from 64.7% to 42.2% from 2010 to 2018 (p<0.001). Adjusted for patient characteristics, the median hospital-level proportion of single-chamber ICDs increased from 42.9% to 50.0%, and the median odds ratio for the use of dual-chamber ICDs was 1.6 and 1.5 in 2010 and 2018, respectively, indicating a decreasing but persistent variation in use.

Results showed that patients undergoing single-chamber ICD implantation were less likely to have a lower left ventricular ejection fraction, and more likely to be Black or African American, have nonischemic cardiomyopathy and undergoing dialysis. Patients undergoing dual-chamber ICD implantation were more likely to be older, have a history of cerebrovascular disease and have a QRS duration >120 ms. Additionally, private and community hospitals were more likely to implant dual-chamber devices, while university hospitals were more likely to implant single-chamber devices.

According to the researchers, single-chamber ICDs were historically used in the landmark randomized clinical trials evaluating the mortality benefit of ICDs. However, prior investigations have demonstrated substantial variation in the use of dual-chamber devices, which is independent of pacing need for patient characteristics. The authors write this variability is likely related to the complexity in the decision to implant a dual-chamber ICD for a given patient, which is dependent on a variety of clinical considerations, including the potential need for pacing in the future, effect of medications on pacing needs, arrhythmia discrimination algorithms, and specific scenarios in which pacing is beneficial.

Regarding the difference in the association in the type of hospital and device type, however, they write the variation is “either owing to unmeasured patient factors or, more likely, differences in individual clinicians, local culture, clustering of graduated fellows practicing in regions where they trained, or local opinion leaders.”

“Variation in care represents gaps in quality of care. Identifying this variation provides an opportunity for better care and renewed efforts in research and clinical quality improvement,” they write. “On the basis of evidence demonstrating no improved outcomes and higher risk of complications with the addition of an atrial lead, more active approaches to changing practice may be indicated to reduce this common low-value practice among patients without a pacing indication.”

The researchers concludes that while new techniques and technology continue to advance and improve the field, further evaluation of established and routine practices would be beneficial as new insight into the understanding of patient-related outcomes becomes available.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Implantable Devices, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Heart Failure, Randomized Controlled Trials as Topic, Renal Dialysis, Cerebrovascular Disorders, Cluster Analysis, Registries, Cardiomyopathies, Ventricular Function, Left, Quality Improvement, Bradycardia, Atrial Flutter, Odds Ratio, Atrial Fibrillation, Stroke Volume, Cross-Sectional Studies, National Cardiovascular Data Registries, EP Device Implant Registry

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