Exploring Optimal Cardiac Electronic Implantable Devices Programming: Reducing Non‐Actionable Alerts and Assessing Clinical Outcomes

Q: What are the key findings of this study?

CIED alert reprogramming reduced mean non-actionable alerts from 6.68 to 2.27 over 90 days without increasing ischemic stroke or sudden cardiac death.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Patients with cardiac implantable electronic devices (CIEDs) generating alerts for atrial fibrillation (AF) or non-sustained ventricular tachycardia (NSVT) (n=536). Intervention: Guideline-based CIED alert reprogramming to censor non-actionable AF and NSVT alerts vs. Standard manufacturer alert programming (patients who did not attend an in-person clinic visit for reprogramming). Primary outcome: Mean number of non-actionable alerts (NAAs) over 90 days pre- vs. post-reprogramming (MD -4.41 (SE 0.480), 74.2% total reduction, p=<0.001).

Q: What does this research mean for the field?

Clinically guided reprogramming of cardiac implantable electronic device alert parameters reduces non-actionable alerts by over 70% without increasing the risk of ischemic stroke or sudden cardiac death. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate whether guideline-based alert reprogramming in cardiac implantable electronic devices reduces non-actionable alerts without worsening clinical outcomes such as ischemic stroke and sudden cardiac death.

Mohamed A. Mostafa; George Bodziock; Lindsey Cotten; Christopher L. Schaich; Amber Seiler; John Dillon; Jonathan Brock; Ross Hansen; P Kozák; Tony Simmons; James Allred; Patrick Whalen; Prashant D. Bhave

doi:10.1111/jce.16789

July 9, 2025Journal of Cardiovascular ElectrophysiologyOpen Access

Exploring Optimal Cardiac Electronic Implantable Devices Programming: Reducing Non‐Actionable Alerts and Assessing Clinical Outcomes

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Key result

CIED alert reprogramming linked to ~66% fewer non-actionable alerts without compromising safety.

MD -4.41 (SE 0.480), 74.2% total reduction
P<0.001
n=536

Figures

Why the study?

The evolution of CIEDs has increased remote transmission data, causing excessive non-actionable alerts and alert fatigue, prompting optimization of alert parameters to minimize these alerts and evaluate clinical outcomes.

Does clinically guided reprogramming of CIED alert parameters reduce non-actionable alerts without increasing the risk of ischemic stroke or sudden cardiac death in patients with CIEDs?

Key Points

To evaluate whether guideline-based alert reprogramming in cardiac implantable electronic devices reduces non-actionable alerts without worsening clinical outcomes such as ischemic stroke and sudden cardiac death.
Analyzed 536 patients with cardiac implantable electronic devices (mean age 75 [15] years, 60.4% male, 83.4% white), comparing 413 reprogrammed patients to 123 control patients.
Reprogrammed devices to censor alerts for atrial fibrillation under 5.5 hours, persistent atrial fibrillation over 1 month with prior alerts, atrial fibrillation under 24 hours on anticoagulation or post-appendage occlusion, and non-sustained ventricular tachycardia.
Tracked non-actionable alerts 90 days pre- and post-reprogramming, with incident ischemic stroke and sudden cardiac death assessed over a median follow-up of 1.8 years.
Non-actionable alerts significantly decreased from 6.68 (SD = 10.02) to 2.27 (SD = 4.58) post-reprogramming (p < 0.001), representing a 74.2% total volume reduction.
Ischemic stroke incidence among patients with atrial fibrillation alerts was 5.2% (n = 15) in the reprogrammed cohort versus 5.4% (n = 5) in controls, showing no significant difference in adjusted logistic regression (OR 0.82, 95% CI 0.27–2.51, p = 0.73).
Sudden cardiac death occurred in 2.3% (n = 3) of reprogrammed patients with non-sustained ventricular tachycardia compared to 9.3% (n = 3) of controls (adjusted OR 0.28, 95% CI 0.05–1.53, p = 0.14).

Study Design

Type

Cohort (n=536)

Multicenter

No

Structured PICO

Does clinically guided reprogramming of CIED alert parameters reduce non-actionable alerts without increasing the risk of ischemic stroke or sudden cardiac death in patients with CIEDs?

P

Population

536 adults (mean age 75 years, 60.4% male) with cardiac implantable electronic devices generating atrial fibrillation or non-sustained ventricular tachycardia alerts at a single US academic center, followed for a median of 1.8 years.

I

Intervention

In-person clinically guided CIED alert reprogramming implemented between April 2022 and December 2022 (n=413) to censor non-actionable alerts (NAA): turning off alerts for AF episodes <5.5 hours, persistent AF >1 month with prior alerts, AF episodes <24 hours in patients with known paroxysmal AF on oral anticoagulants (OAC) or with prior left atrial appendage occlusion/surgical excision, and NSVT episodes (ventricular high-rate episodes not requiring ATP or shock therapy) on defibrillator platforms.

C

Comparator

Control group (n=123) of patients with CIEDs who did not attend an in-person clinic visit during the study timeframe and therefore received no alert reprogramming changes (remained on standard/chronic manufacturer preset or prior alert settings).

O

Outcome

Burden of non-actionable alerts (NAAs) tracked over 90 days pre- and post-reprogramming, and safety clinical outcomes (clinically adjudicated incident ischemic stroke in patients with AF alerts and sudden cardiac death [SCD] in patients with NSVT alerts) over a median 1.8-year follow-up.safety

Main Result

Mean Difference: -4.41

Absolute Event Rate: 2.27% vs 6.68%

p-value: p=<0.001

Clinically guided reprogramming of CIED alert thresholds for subclinical AF and NSVT reduced non-actionable remote monitoring alerts by 74.2% over 90 days without increasing the risk of ischemic stroke or sudden cardiac death over 1.8 years.

Limitations

Single-center retrospective study limiting generalizability
Potential selection bias and confounding in the control group (composed of patients who did not attend an in-person clinic visit)
Small number of clinical outcome events limiting statistical power in regression models
Potential underestimation of sudden cardiac death due to lack of death certificates for all patients and reliance on 3-month remote transmissions
Did not evaluate frequency of device-based therapies such as ICD shocks or anti-tachycardia pacing
Single-center study limiting generalizability to other populations
Potential selection bias and confounding because the control group consisted of patients who did not attend an in-person device clinic appointment during the study window
Small number of clinical outcome events (stroke and SCD) weakening the statistical power of the regression models
Potential underestimation of SCD cases due to lack of death certificates for all patients, device deactivation as part of end-of-life protocols, and reliance on scheduled 3-month remote transmissions
Did not evaluate other potentially relevant device-based endpoints such as frequency of ICD shocks or anti-tachycardia pacing, nor ventricular rate control during AF episodes

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Answers are grounded in this paper and cite their sources.

Implication

Reprogramming may reduce non-actionable CIED alerts without raising stroke or SCD risk; leaves open randomized confirmation before practice change.

Abstract

BACKGROUND: The rapid evolution of cardiac implantable electronic devices (CIEDs) has increased remote transmission data, leading to excessive non-actionable alerts (NAA) and alert fatigue. OBJECTIVE: Optimize alert parameters to minimize NAA and evaluate the impact on clinical outcomes. METHODS: We included 536 participants (mean age 75 (15) years, 60.4% male, 83.4% white) with CIEDs. In 413 patients, CIEDs were reprogrammed to censor alerts as follows: atrial fibrillation (AF) episodes < 5.5 h, persistent AF > 1 month with prior alerts, AF < 24 h on anticoagulation or with prior appendage occlusion, and non-sustained ventricular tachycardia (NSVT) in defibrillator platforms. NAAs were tracked 90-days pre- and post-reprogramming. Incident ischemic stroke and sudden cardiac death (SCD) were assessed over a median 1.8-year follow-up. Logistic regression models examined associations between reprogramming and outcomes. RESULTS: Reprogramming was implemented for AF alerts (69.5%, n = 287) and NSVT alerts (30.5%, n = 126). After reprogramming, NAAs significantly decreased from 6.68 (SD = 10.02) to 2.27 (SD = 4.58), p < 0.001. During follow-up, ischemic stroke rates in AF patients were similar between reprogrammed (5.2%, n = 15) and control groups (5.4%, n = 5). In those with NSVT alerts, SCD incidence was lower in reprogrammed (2.3%, n = 3) versus controls (9.3%, n = 3). In logistic regression models adjusted for demographics, CHA₂DS₂VASC score, anticoagulation status, and prior stroke history, there was no statistically significant difference in stroke risk between groups (OR 0.82 [0.27-2.51]). CONCLUSIONS: Guideline-based alert parameters in CIED patients significantly reduced NAA burden with no increasing in adverse outcomes in patients with device-detected AF or NSVT alerts. This approach may reduce noise and safely improve efficiency.

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Cite This Study

Mostafa et al. (2025) conducted a cohort in Patients with cardiac implantable electronic devices (CIEDs) generating alerts for atrial fibrillation (AF) or non-sustained ventricular tachycardia (NSVT) (n=536). Guideline-based CIED alert reprogramming to censor non-actionable AF and NSVT alerts vs. Standard manufacturer alert programming (patients who did not attend an in-person clinic visit for reprogramming) was evaluated on Mean number of non-actionable alerts (NAAs) over 90 days pre- vs. post-reprogramming (MD -4.41 (SE 0.480), 74.2% total reduction, p=<0.001). CIED alert reprogramming reduced mean non-actionable alerts from 6.68 to 2.27 over 90 days without increasing ischemic stroke or sudden cardiac death.

synapsesocial.com/papers/6a8ac68360c8c47a9ee3a1a0 https://doi.org/10.1111/jce.16789

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Exploring Optimal Cardiac Electronic Implantable Devices Programming: Reducing Non‐Actionable Alerts and Assessing Clinical Outcomes

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Exploring Optimal Cardiac Electronic Implantable Devices Programming: Reducing Non‐Actionable Alerts and Assessing Clinical Outcomes

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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