Intrinsic versus conventional antitachycardia pacing for ventricular tachycardia: a systematic review and meta-analysis

Background Conventional antitachycardia pacing (cATP) reduces the shock burden in patients with monomorphic ventricular tachycardia (MVT) who have received an implantable cardioverter-defibrillator (ICD). Intrinsic ATP (iATP) is an automated algorithm that adjusts pacing sequences based on real-time post-pacing intervals; however, its efficacy and safety compared to cATP remains uncertain. Purpose We aimed to perform a meta-analysis to evaluate the efficacy and safety of iATP compared with cATP for MVT termination in patients with ICDs or cardiac resynchronization therapy-defibrillators (CRT-Ds). Methods We systematically searched PubMed, Scopus, and Web of Science from inception to February 2026 for studies evaluating iATP versus cATP for MVT in ICD and CRT-D recipients. To mitigate unit-of-analysis errors from recurrent MVT episodes, quantitative synthesis was stratified into two models: a proportional meta-analysis of iATP efficacy utilizing Generalized Estimating Equation (GEE)-adjusted estimates to account for intra-patient correlation, and a pairwise comparative meta-analysis of iATP versus cATP utilizing unadjusted raw episodic counts. Random-effects models (Mantel-Haenszel for risk ratios [RR]; inverse variance with logit transformation for proportions) were applied. Heterogeneity was quantified using the I2 statistic. Results We included four observational studies comprising 5,498 unique patients (mean age 66.2–73.5 years; 71.3–82.6% male; mean LVEF 30.0–40.9%) and a total of 6,854 evaluated MVT episodes. In the proportional meta-analysis of 3,068 iATP episodes, the GEE-adjusted overall success rate was 87.3% (95% CI 86.1–88.4%), with an 83.7% (95% CI 81.2–85.9%) success rate for Fast VT. In the pairwise comparative analysis evaluating 2,824 iATP and 4,030 cATP unadjusted episodes, overall VT termination success was not statistically different (RR 1.03; 95% CI 0.98–1.08; p=0.30; I2=62%). However, iATP was associated with a statistically significant 58% relative risk reduction in MVT acceleration requiring shock compared with cATP (RR 0.42; 95% CI 0.30–0.59; p<0.001; I2=0%). Conclusion These findings suggest that iATP provides high MVT termination rates, including in the fast VT zone. While the overall termination efficacy appears similar to that of cATP, iATP is associated with a significantly reduced risk of MVT acceleration requiring shock.Figure 1.iATP vs cATP (JPG)Figure 1.iATP vs cATP (PNG)