Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease

Background - Implantable cardioverter-defibrillators (ICDs) can terminate some ventricular tachycardias (VTs) painlessly with antitachycardia pacing (ATP). ATP has not routinely been applied for VT >188 bpm because of concerns about efficacy, risk of acceleration, and delay of definitive shock therapy. This prospective, multicenter study evaluated the efficacy of empirical ATP to terminate fast VT (FVT; >188 bpm). Methods and Results - Two hundred twenty coronary artery disease patients received ICDs for standard indications. Empirical, standardized therapy was programmed so that all FVT episodes (average cycle length [CL] 240 to 320 ms, 250 to 188 bpm) were treated with 2 ATP sequences (8-pulse burst pacing train at 88% of the FVT CL) before shock delivery. A total of 1100 episodes of spontaneous ventricular tachyarrhythmias occurred during a mean of 6.9±3.6 months of follow-up. Fifty-seven percent were classified as slow VT (CL≥320 ms), 40% as FVT (240 ms≤CL<320 ms), and 3% as ventricular fibrillation (CL<240 ms). A total of 446 FVT episodes, mean CL=301±24 ms, occurred in 52 patients (median 2 episodes per patient). ATP terminated 396 FVT episodes (89%), with an adjusted efficacy of 77% (95% CI 68% to 83%). VT acceleration caused by ATP occurred in 10 FVT episodes (4%). FVT arrhythmic syncope occurred on 9 occasions (2%) in 4 patients. Conclusions - FVT (CL<320 ms) is common in ICD patients. ATP can terminate 3 of 4 of these episodes with a low incidence of acceleration and syncope. ATP for FVT may safely reduce the morbidity of painful shocks.