Societies Update Appropriate Use Criteria for Cardiac Implantable Devices

Multiple societies covering cardiovascular medicine, electrophysiology, heart failure, and imaging have released updated appropriate use criteria (AUC) for various cardiac implantable electronic devices, 12 years after the last ones.

The document, co-chaired by Andrea Russo, MD, (Cooper University Health Care, Camden, NJ), and Milind Desai, MD (Cleveland Clinic, OH), goes over 335 common clinical scenarios in which implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT), or pacing may be used and provides ratings of appropriateness with support from current practice guidelines and studies of device implantation.

These criteria were last updated in 2013, so this latest iteration, published recently online in the Journal of the American College of Cardiology, “was needed to reflect new technologies, emerging clinical evidence, and a shift towards personalized and patient-centered care in the management of cardiac arrhythmias and heart failure,” Desai and vice chair Monika Do, DNP (Vanderbilt University, Nashville, TN), said in comments emailed to TCTMD.

“It builds on the foundation set in 2013 but incorporates more advanced tools and evidence to guide clinicians in the decision-making process for device therapy,” they continued. “The evolving landscape of cardiovascular disease treatment, monitoring, and advanced clinical trials made this update essential for maintaining optimal care standards for patients who might benefit from these lifesaving technologies.”

Eight societies were involved in crafting the new AUC: the American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance.

A Changing Landscape

The document incorporates new procedures and technologies that have either become more widely used since 2013 or weren’t yet approved by the US Food and Drug Administration, including conduction system pacing (ie, His-bundle or left bundle area pacing), leadless pacing, and cardiac contractility modulation. The authors also added more heart failure sections covering ICD implantation in the setting of left ventricular assist devices (LVADs) and after heart transplantation.

Those join sections on ICD implantation for primary and secondary prevention; device use in the setting of specific comorbidities that may either reduce life expectancy or increase procedural risk; elective ICD generator replacement; dual-chamber ICD implantation in patients without an indication for CRT; CRT in patients without a prior implant, and implantation of a completely subcutaneous ICD.

Desai and Do said the updated AUC expand indications and populations in some cases, addressing, for instance, the use of ICDs and CRT in patients with heart failure but higher ejection fractions, or patients with certain conduction abnormalities.

The AUC, they added, also reflect the results of important trials published since 2013 that have influenced the management and treatment of heart failure and arrhythmias—studies such as DAPA-HF, CABANA, ATLAS S-ICD, DANISH, and EMPEROR-Reduced.

“The 2025 AUC needed to address these new treatments and how they interact with the use of cardiac devices, including the potential for medication therapy to reduce reliance on devices in some cases,” they said.

In addition, “new evidence has provided a more nuanced understanding of patient populations, enabling more precise risk stratification for device therapy,” Desai and Do said, pointing out that clinicians should consider a variety of factors like comorbidities and genetic susceptibility to provide more personalized care.

The earlier version of the AUC document primarily leaned on LVEF and NYHA class to determine eligibility for device therapy, but the 2025 version incorporates several additional variables, like electrophysiological factors, genetic predisposition, and symptoms, to better tailor care.

The writers also placed a greater emphasis on patient-centered care and shared decision-making, “recognizing that modern medicine increasingly values the patient’s voice in their treatment decisions,” they said. “This approach contrasts with the more rigid, algorithmic approach of the previous document.”

Overall, this type of reference can be used to complement practice guidelines, Desai and Do indicated.

“While the AUC document provides specific recommendations on when and how to use devices like pacemakers, ICDs, and CRT based on patient characteristics and clinical scenarios, clinical practice guidelines offer broader management strategies for conditions such as heart failure, arrhythmias, and ischemic heart disease, incorporating pharmacological, lifestyle, and surgical interventions,” they said. “By integrating both, clinicians can make well-rounded decisions that align device therapy with overall treatment goals, patient preferences, and emerging evidence, while ensuring continuous monitoring and follow-up for optimal outcomes.”

On the policy front, they added, AUC “can better inform reimbursement policies, healthcare resource distribution, and regulatory criteria, supporting more rational, cost-effective use of cardiac devices and fostering quality improvement initiatives across healthcare systems.”