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Anti-tachycardia Pacing: Mechanism, History and Contemporary Implementation

  • Arrhythmia (R Kabra, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Implantable cardioverter-defibrillator (ICD) shocks, whether appropriate or inappropriate, are associated with significant morbidity and mortality. Anti-tachycardia pacing (ATP) is a painless treatment for reentrant ventricular tachycardia (VT), and it has been shown to be effective for treating fast VT with low risk of acceleration or syncope. Yet there is substantial difference in the frequency, rate, and mechanism of VT in ICD recipients implanted for primary versus secondary prevention indications and the benefit of ATP differs accordingly. We review the mechanism of ATP, the history of ATP through important clinical trials, and contemporary consideration of its therapeutic value.

Recent Findings

VT episodes are significantly more likely to spontaneously terminate in primary prevention patients. The value of ATP is overestimated, particularly in patients with primary prevention ICD indications.

Summary

Over the past 30 years, advances in technologies coupled with our understanding of appropriate ICD programming have drawn into question the value of empiric programming of ATP in primary prevention cohorts. Relatively long ICD therapy delays are safe and significantly reduce unnecessary ATP interventions in primary and secondary prevention cohorts. The mortality benefit of ICDs in most primary prevention patients may be derived from shock therapy alone.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med. 1996;335(26):1933–1940.

  2. Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G. A randomized study of the prevention of sudden death in patients with coronary artery disease. Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 1999;341(25):1882–1890.

  3. Moss AJ, Fadl Y, Zareba W, Cannom DS, Hall WJ, Defibrillator Implantation Trial Research G. Survival benefit with an implanted defibrillator in relation to mortality risk in chronic coronary heart disease. Am J Cardiol. 2001;88(5):516–520.

  4. Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140–50.

    Article  CAS  Google Scholar 

  5. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352(3):225–37.

    Article  CAS  Google Scholar 

  6. Antiarrhythmics versus Implantable Defibrillators I. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997;337(22):1576–1583.

  7. Kuck KH, Cappato R, Siebels J, Ruppel R. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest : the Cardiac Arrest Study Hamburg (CASH). Circulation. 2000;102(7):748–54.

    Article  CAS  Google Scholar 

  8. Connolly SJ, Gent M, Roberts RS, et al. Canadian implantable defibrillator study (CIDS): a randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation. 2000;101(11):1297–302.

    Article  CAS  Google Scholar 

  9. Sweeney MO, Wathen MS, Volosin K, et al. Appropriate and inappropriate ventricular therapies, quality of life, and mortality among primary and secondary prevention implantable cardioverter defibrillator patients: results from the Pacing Fast VT REduces Shock ThErapies (PainFREE Rx II) trial. Circulation. 2005;111(22):2898–905.

    Article  CAS  Google Scholar 

  10. Daubert JP, Zareba W, Cannom DS, et al. Inappropriate implantable cardioverter-defibrillator shocks in MADIT II: frequency, mechanisms, predictors, and survival impact. J Am Coll Cardiol. 2008;51(14):1357–65.

    Article  Google Scholar 

  11. Schron EB, Exner DV, Yao Q, et al. Quality of life in the antiarrhythmics versus implantable defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator shocks. Circulation. 2002;105(5):589–94.

    Article  Google Scholar 

  12. Poole JE, Johnson GW, Hellkamp AS, et al. Prognostic importance of defibrillator shocks in patients with heart failure. N Engl J Med. 2008;359(10):1009–17.

    Article  CAS  Google Scholar 

  13. Ladwig KH, Baumert J, Marten-Mittag B, Kolb C, Zrenner B, Schmitt C. Posttraumatic stress symptoms and predicted mortality in patients with implantable cardioverter-defibrillators: results from the prospective living with an implanted cardioverter-defibrillator study. Arch Gen Psychiatry. 2008;65(11):1324–30.

    Article  Google Scholar 

  14. Mirowski M, Reid PR, Mower MM, et al. Termination of malignant ventricular arrhythmias with an implanted automatic defibrillator in human beings. N Engl J Med. 1980;303(6):322–4.

    Article  CAS  Google Scholar 

  15. Leitch JW, Gillis AM, Wyse DG, et al. Reduction in defibrillator shocks with an implantable device combining antitachycardia pacing and shock therapy. J Am Coll Cardiol. 1991;18(1):145–51.

    Article  CAS  Google Scholar 

  16. Fromer M, Brachmann J, Block M, et al. Efficacy of automatic multimodal device therapy for ventricular tachyarrhythmias as delivered by a new implantable pacing cardioverter-defibrillator. Results of a European multicenter study of 102 implants. Circulation. 1992;86(2):363–374.

  17. Sanders P, Connolly AT, Nabutovsky Y, Fischer A, Saeed M. Increased Hospitalizations and Overall Healthcare Utilization in Patients Receiving Implantable Cardioverter-Defibrillator Shocks Compared With Antitachycardia Pacing. JACC Clin Electrophysiol. 2018;4(2):243–53.

    Article  Google Scholar 

  18. Wilkoff BL, Ousdigian KT, Sterns LD, et al. A comparison of empiric to physician-tailored programming of implantable cardioverter-defibrillators: results from the prospective randomized multicenter EMPIRIC trial. J Am Coll Cardiol. 2006;48(2):330–9.

    Article  Google Scholar 

  19. Schaumann A, von zur Muhlen F, Herse B, Gonska BD, Kreuzer H. Empirical versus tested antitachycardia pacing in implantable cardioverter defibrillators: a prospective study including 200 patients. Circulation. 1998;97(1):66–74.

  20. Peinado R, Almendral J, Rius T, et al. Randomized, prospective comparison of four burst pacing algorithms for spontaneous ventricular tachycardia. Am J Cardiol. 1998;82(11):1422–1425, A1428–1429.

  21. Yee R, Birgersdotter-Green U, Belk P, Jackson T, Christensen J, Wathen MS. The relationship between pacing site and induction or termination of sustained monomorphic ventricular tachycardia by antitachycardia pacing. Pacing Clin Electrophysiol. 2010;33(1):27–32.

    Article  Google Scholar 

  22. Rosenthal ME, Stamato NJ, Almendral JM, et al. Influence of the site of stimulation on the resetting phenomenon in ventricular tachycardia. Am J Cardiol. 1986;58(10):970–6.

    Article  CAS  Google Scholar 

  23. Waxman HL, Cain ME, Greenspan AM, Josephson ME. Termination of ventricular tachycardia with ventricular stimulation: salutary effect of increased current strength. Circulation. 1982;65(4):800–4.

    Article  CAS  Google Scholar 

  24. Martins RP, Blangy H, Muresan L, et al. Safety and efficacy of programming a high number of antitachycardia pacing attempts for fast ventricular tachycardia: a prospective study. Europace. 2012;14(10):1457–64.

    Article  Google Scholar 

  25. Gasparini M, Anselme F, Clementy J, et al. BIVentricular versus right ventricular antitachycardia pacing to terminate ventricular tachyarrhythmias in patients receiving cardiac resynchronization therapy: the ADVANCE CRT-D Trial. Am Heart J. 2010;159(6):1116–1123 e1112.

  26. Calkins H, el-Atassi R, Kalbfleisch S, Langberg J, Morady F. Comparison of fixed burst versus decremental burst pacing for termination of ventricular tachycardia. Pacing Clin Electrophysiol. 1993;16(1 Pt 1):26–32.

  27. Charos GS, Haffajee CI, Gold RL, Bishop RL, Berkovits BV, Alpert JS. A theoretically and practically more effective method for interruption of ventricular tachycardia: self-adapting autodecremental overdrive pacing. Circulation. 1986;73(2):309–15.

    Article  CAS  Google Scholar 

  28. Gillis AM, Leitch JW, Sheldon RS, et al. A prospective randomized comparison of autodecremental pacing to burst pacing in device therapy for chronic ventricular tachycardia secondary to coronary artery disease. Am J Cardiol. 1993;72(15):1146–51.

    Article  CAS  Google Scholar 

  29. Porterfield JG, Porterfield LM, Smith BA, Bray L, Voshage L, Martinez A. Conversion rates of induced versus spontaneous ventricular tachycardia by a third generation cardioverter defibrillator. The VENTAK PRx Phase I Investigators. Pacing Clin Electrophysiol. 1993;16(1 Pt 2):170–173.

  30. Gulizia MM, Piraino L, Scherillo M, et al. A randomized study to compare ramp versus burst antitachycardia pacing therapies to treat fast ventricular tachyarrhythmias in patients with implantable cardioverter defibrillators: the PITAGORA ICD trial. Circ Arrhythm Electrophysiol. 2009;2(2):146–53.

    Article  Google Scholar 

  31. de Sousa MR, Cota GF, Burger AL, Pezawas T. Comparison of burst versus ramp antitachycardia pacing therapy for ventricular tachycardia: A meta-analysis. J Cardiovasc Electrophysiol. 2021;32(3):842–50.

    Article  Google Scholar 

  32. Yee R, Fisher JD, Birgersdotter-Green U, et al. Initial Clinical Experience With a New Automated Antitachycardia Pacing Algorithm: Feasibility and Safety in an Ambulatory Patient Cohort. Circ Arrhythm Electrophysiol. 2017;10(9).

  33. Wathen MS, Sweeney MO, DeGroot PJ, et al. Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease. Circulation. 2001;104(7):796–801.

    Article  CAS  Google Scholar 

  34. Wathen MS, DeGroot PJ, Sweeney MO, et al. Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks for spontaneous rapid ventricular tachycardia in patients with implantable cardioverter-defibrillators: Pacing Fast Ventricular Tachycardia Reduces Shock Therapies (PainFREE Rx II) trial results. Circulation. 2004;110(17):2591–6.

    Article  Google Scholar 

  35. Schoels W, Steinhaus D, Johnson WB, et al. Optimizing implantable cardioverter-defibrillator treatment of rapid ventricular tachycardia: antitachycardia pacing therapy during charging. Heart Rhythm. 2007;4(7):879–85.

    Article  Google Scholar 

  36. Wilkoff BL, Williamson BD, Stern RS, et al. Strategic programming of detection and therapy parameters in implantable cardioverter-defibrillators reduces shocks in primary prevention patients: results from the PREPARE (Primary Prevention Parameters Evaluation) study. J Am Coll Cardiol. 2008;52(7):541–50.

    Article  Google Scholar 

  37. Santini M, Lunati M, Defaye P, et al. Prospective multicenter randomized trial of fast ventricular tachycardia termination by prolonged versus conventional anti-tachyarrhythmia burst pacing in implantable cardioverter-defibrillator patients-Atp DeliVery for pAiNless ICD thErapy (ADVANCE-D) Trial results. J Interv Card Electrophysiol. 2010;27(2):127–35.

    Article  Google Scholar 

  38. Saeed M, Hanna I, Robotis D, et al. Programming implantable cardioverter-defibrillators in patients with primary prevention indication to prolong time to first shock: results from the PROVIDE study. J Cardiovasc Electrophysiol. 2014;25(1):52–9.

    Article  Google Scholar 

  39. Windecker S, Ideker RE, Plumb VJ, Kay GN, Walcott GP, Epstein AE. The influence of ventricular fibrillation duration on defibrillation efficacy using biphasic waveforms in humans. J Am Coll Cardiol. 1999;33(1):33–8.

    Article  CAS  Google Scholar 

  40. Burger AL, Stojkovic S, Schmidinger H, Ristl R, Pezawas T. Defensive Implantable Cardioverter-Defibrillator Programming Is Safe and Reduces Inappropriate Therapy- Comparison of 3 Programming Strategies in 1,471 Patients. Circ J. 2018;82(12):2976–82.

    Article  Google Scholar 

  41. Moss AJ, Schuger C, Beck CA, et al. Reduction in inappropriate therapy and mortality through ICD programming. N Engl J Med. 2012;367(24):2275–83.

    Article  CAS  Google Scholar 

  42. Gasparini M, Proclemer A, Klersy C, et al. 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. JAMA. 2013;309(18):1903–11.

    Article  CAS  Google Scholar 

  43. Gasparini M, Menozzi C, Proclemer A, et al. A simplified biventricular defibrillator with fixed long detection intervals reduces implantable cardioverter defibrillator (ICD) interventions and heart failure hospitalizations in patients with non-ischaemic cardiomyopathy implanted for primary prevention: the RELEVANT [Role of long dEtection window programming in patients with LEft VentriculAr dysfunction, Non-ischemic eTiology in primary prevention treated with a biventricular ICD] study. Eur Heart J. 2009;30(22):2758–67.

    Article  Google Scholar 

  44. Germano JJ, Reynolds M, Essebag V, Josephson ME. Frequency and causes of implantable cardioverter-defibrillator therapies: is device therapy proarrhythmic? Am J Cardiol. 2006;97(8):1255–61.

    Article  Google Scholar 

  45. Ellenbogen KA, Levine JH, Berger RD, et al. Are implantable cardioverter defibrillator shocks a surrogate for sudden cardiac death in patients with nonischemic cardiomyopathy? Circulation. 2006;113(6):776–82.

    Article  Google Scholar 

  46. Wilkoff BL, Hess M, Young J, Abraham WT. Differences in tachyarrhythmia detection and implantable cardioverter defibrillator therapy by primary or secondary prevention indication in cardiac resynchronization therapy patients. J Cardiovasc Electrophysiol. 2004;15(9):1002–9.

    Article  Google Scholar 

  47. •• Schuger C, Daubert JP, Zareba W, et al. Reassessing the role of antitachycardia pacing in fast ventricular arrhythmias in primary prevention implantable cardioverter-defibrillator recipients: Results from MADIT-RIT. Heart Rhythm. 2021;18(3):399–403. This secondary analysis of the MADIT-RIT study questioned the value of appropriate ATP for FVT in a primary prevention cohort as the benefit of ATP for treating FVT may be falsely elevated if ATP is prematurely initiated for FVT that is predestined to terminate.

    Article  Google Scholar 

  48. Ruwald AC, Schuger C, Moss AJ, et al. Mortality reduction in relation to implantable cardioverter defibrillator programming in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy (MADIT-RIT). Circ Arrhythm Electrophysiol. 2014;7(5):785–92.

    Article  Google Scholar 

  49. • Schuger CD, Ando K, Cantillon DJ, et al. Assessment of primary prevention patients receiving an ICD - Systematic evaluation of ATP: APPRAISE ATP. Heart Rhythm O2. 2021;2(4):405–11. This ongoing study may provide insight on the impact of unnecessary ATP, and whether ATP may be more beneficial in a particular subgroup of patients.

    Article  Google Scholar 

  50. Wilkoff BL, Fauchier L, Stiles MK, et al. 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing. Europace. 2016;18(2):159–83.

    Article  Google Scholar 

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Authors and Affiliations

  1. Evans Department of Medicine, Cardiovascular Medicine Section, Boston University School of Medicine, 830 Harrison Avenue, Moakley Building, Suite 3500, Boston, MA, 02118, USA

    Subhasree Panchangam MD, Kevin M. Monahan MD & Robert H. Helm MD, FHRS

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  1. Subhasree Panchangam MD
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  2. Kevin M. Monahan MD
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  3. Robert H. Helm MD, FHRS
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Correspondence to Robert H. Helm MD, FHRS.

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Panchangam, S., Monahan, K.M. & Helm, R.H. Anti-tachycardia Pacing: Mechanism, History and Contemporary Implementation. Curr Treat Options Cardio Med 24, 27–40 (2022). https://doi.org/10.1007/s11936-022-00959-0

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