Letter by Imberti et al Regarding Article, "DREAM-ICD-II Study".

Abstract

HomeCirculationVol. 146, No. 8Letter by Imberti et al Regarding Article, “DREAM-ICD-II Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Imberti et al Regarding Article, “DREAM-ICD-II Study” Jacopo F. Imberti, MD, Marco Vitolo, MD and Giuseppe Boriani, MD, PhD Jacopo F. ImbertiJacopo F. Imberti https://orcid.org/0000-0003-3403-3364 Cardiology Division, Department of Biomedical, Metabolic, and Neural Sciences, Policlinico di Modena (J.F.I., M.V., G.B.), University of Modena and Reggio Emilia, Italy. Clinical and Experimental Medicine PhD Program (J.F.I., M.V.), University of Modena and Reggio Emilia, Italy. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (J.F.I., M.V.). Search for more papers by this author , Marco VitoloMarco Vitolo https://orcid.org/0000-0002-5196-6249 Cardiology Division, Department of Biomedical, Metabolic, and Neural Sciences, Policlinico di Modena (J.F.I., M.V., G.B.), University of Modena and Reggio Emilia, Italy. Clinical and Experimental Medicine PhD Program (J.F.I., M.V.), University of Modena and Reggio Emilia, Italy. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, United Kingdom (J.F.I., M.V.). Search for more papers by this author and Giuseppe BorianiGiuseppe Boriani https://orcid.org/0000-0002-9820-4815 Cardiology Division, Department of Biomedical, Metabolic, and Neural Sciences, Policlinico di Modena (J.F.I., M.V., G.B.), University of Modena and Reggio Emilia, Italy. Search for more papers by this author Originally published22 Aug 2022https://doi.org/10.1161/CIRCULATIONAHA.122.059167Circulation. 2022;146:e89–e90To the Editor:We read the article by Steinberg et al1 with interest. The authors reported a low incidence rate of appropriate implantable cardioverter defibrillator therapies resulting in sudden cardiac incapacitation in patients implanted for secondary prevention of sudden cardiac death. The risk declined significantly after the first 3 months and was much lower compared with previous reports. Patients had implantable cardioverter defibrillator programming entirely adherent with guidelines. Antitachycardia pacing was considered as part of the standardized programming and accounted for approximately one-third of all the appropriate implantable cardioverter defibrillator interventions. Modern programming reduces implantable cardioverter defibrillator shocks,2 and antitachycardia pacing therapies are effective in terminating fast ventricular tachycardia, reducing implantable cardioverter defibrillator shocks.3 Approximately 12% of patients were implanted with a subcutaneous implantable cardioverter defibrillator, which, being first approved by the US Food and Drug Administration in 2012, is a type of implant not considered in previous studies.Driving bans after implantation of a secondary prevention implantable cardioverter defibrillator vary significantly worldwide, ranging from 2 to 12 months,4 reflecting the lack of robust and up-to-date scientific data. Current national regulatory documents are old and were developed on the basis of historical data not taking into account improvements in implantable cardioverter defibrillator technologies, patient treatments, and driving environment. It is time to overcome the heterogeneity of national regulations and adopt a standardized approach to evaluate the fitness to drive of patients with implantable cardioverter defibrillators, potentially reducing uncertainty and confusion for both physicians and patients.The study by Steinberg et al1 leaves some questions open. Robust predictors of arrhythmic syncope during implantable cardioverter defibrillator therapies are needed to refine the evidence-based approach to driving restrictions and identify patients truly at high risk. In particular, the effect of new heart failure therapies, antiarrhythmic drugs, and catheter ablation in reducing the risk of arrhythmia recurrence have not been tested. Moreover, it would be interesting to know how many arrhythmic syncope episodes were associated with shock-only programming as compared with antitachycardia pacing–based programming in patients categorized according to different substrates (patients with purely arrhythmogenic diseases versus ventricular tachyarrhythmias in the context of heart failure). Data from multicenter registries could provide some real-world data and contribute to improve knowledge.5We agree with the proposal by Steinberg et al1 to reduce the period of driving bans after implantable cardioverter defibrillator implant in secondary prevention to 3 months, as already applied in some countries.4 However, we also stress the need for improved tailoring of decision-making according to the type of arrhythmia (ventricular tachycardia or ventricular fibrillation), the potential occurrence of storm, and treatment with catheter ablation in combination with implantable cardioverter defibrillator. A better approach to driving restrictions could improve information, education, acceptance, and adherence to treatment for patients presenting with ventricular tachyarrhythmia.Article InformationDisclosures Dr Boriani reports receiving small speaker fees from Medtronic, Boston, Boehringer Ingelheim, and Bayer. No fees were received personally. Drs Imberti and Vitolo report no conflicts.FootnotesCirculation is available at www.ahajournals.org/journal/circ