ACC/AHA/HRS 2025 Appropriate Use Criteria for ICD, CRT, and Pacing

Authors, Journal, Affiliations, Type, DOI

• Authors: Russo AM, Desai MY, Do MM, et al. (writing committee); 17-member rating panel; 8-society endorsement
• Societies: ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR
• Journal: Journal of the American College of Cardiology, 2025;85(11):1213–1285
• Type: Appropriate Use Criteria (AUC) — Modified Delphi expert consensus; NOT a clinical practice guideline
• DOI: 10.1016/j.jacc.2024.11.023

Overview

This 2025 AUC document defines appropriateness for 335 clinical scenarios across 12 device domains: secondary-prevention ICD, primary-prevention ICD (CAD and NICM), specific etiology ICD, genetic condition ICD, comorbidity modifiers, generator replacement, dual-chamber ICD, subcutaneous ICD (S-ICD), CRT, LVAD+ICD, post-transplant ICD, cardiac contractility modulation (CCM), leadless pacing, and conduction system pacing (CSP). Using a 17-member modified Delphi process with 1–9 scoring, scenarios are rated Appropriate (A, ≥7), May Be Appropriate (M, 4–6), or Rarely Appropriate (R, ≤3). This is an expert consensus document — not evidence-based systematic review — and updates prior AUC from 2013 to incorporate modern device technology and evidence (PRAETORIAN, UNTOUCHED, DANISH trial caveats, dual-chamber leadless pacing, CSP).

Keywords

ICD, CRT, S-ICD, leadless pacing, conduction system pacing, CCM, appropriate use criteria, primary prevention, secondary prevention, NICM, cardiomyopathy, HCM, ARVC, LMNA, cardiac sarcoidosis, LVAD, cardiac transplant

Key Takeaways

Section 1 — Secondary Prevention ICD

• Genetic channelopathies (LQTS, SQTS, CPVT, Brugada) post-sustained VT/VF: A(9) across all scenarios
• ARVC post-VT/VF: A(9); HCM post-VT/VF: A(9)
• CAD without recent MI + documented VF: A(8–9) regardless of LVEF — no waiting period for secondary prevention
• Acute MI (<40 days) with sustained VT/VF during hospitalisation: R(2–3) if VT/VF occurs within 48h of acute MI (presumed transient); M(5–6) if later in admission and LVEF ≤35%
• VF secondary to reversible cause (electrolyte abnormality, drug toxicity, acute ischaemia with revascularisation): R(1–3)

Section 2 — Primary Prevention ICD: CAD

• 40-day post-MI waiting period applies to all primary prevention scenarios in CAD
• MADIT-II basis: CAD + LVEF ≤30% + >40 days post-MI + ≥3 months post-revascularisation: A(8–9)
• CAD + LVEF 31–35% + NSVT + EPS-inducible sustained VT: A(7–8)
• CAD + LVEF 31–35% + no NSVT: M(4–5); CAD + LVEF 36–49% + NSVT + EPS inducible: M(5–6)
• Post-revascularisation waiting period: ≥90 days after PCI/CABG before re-evaluation; ICD not appropriate within 90 days unless other clear indication
• NICM criteria do NOT apply to ischaemic aetiology

Section 3 — Primary Prevention ICD: NICM

• <3 months GDMT: R(1–3) across all age groups — GDMT may improve LVEF
• ≥3 months GDMT + LVEF ≤35% + NYHA II–III:
  • Age <75: A(7–9)
  • Age 75–84: A(7)
  • Age ≥85: M(5–6) — reduced life expectancy and competing mortality
• ≥3 months GDMT + LVEF ≤35% + NYHA IV:
  • On transplant list / LVAD candidate: A(7)
  • Refractory, not a device candidate: R(2)
• LGE-positive NICM + LVEF 36–49%: M(5–6) — emerging evidence but not yet sufficient for A
• DANISH caveat: DANISH trial GDMT did not include SGLT2i or sacubitril–valsartan; modern GDMT may further improve LVEF and reduce ICD benefit; expert opinion that ≥3 months optimal GDMT should be achieved before ICD implantation

Section 4 — Specific Etiology Primary Prevention ICD

Ratings apply regardless of GDMT duration given disease-specific arrhythmic mechanisms:

• Giant-cell myocarditis + LVEF ≤35%: A(7–8)
• Cardiac sarcoidosis + LVEF ≤35%: A(7); cardiac sarcoidosis + LVEF 36–49% with LGE or AV block history: M(6)
• Myotonic dystrophy type 1 + PR >240ms or QRS >120ms: A(8); without conduction disease: M(5)
• Chagas cardiomyopathy + LVEF ≤35%: A(8); LVEF 36–49% + NSVT: M(6)
• ATTR amyloidosis + LVEF ≤35% + NYHA II–III: M(6); NYHA IV: M(5)
• Acute lymphocytic myocarditis, recovering: M(4) at acute stage; R(3) once recovered with normalised LVEF

Section 5 — Genetic Conditions Primary Prevention ICD

• HCM + ≥1 major SCD risk factor (LVEF <50%, massive hypertrophy ≥30mm, prior unexplained syncope, family history SCD, NSVT, abnormal BP response): A(8)
• ARVC without arrhythmia symptoms but ≥1 risk factor (syncope, extensive RV dysfunction, NSVT): A(7)
• LMNA mutation + LVEF 35–45% + ≥1 risk factor: A(7); LVEF ≤35%: A(8)
• Gene carrier with normal echocardiogram and ECG: M(4) — prophylactic ICD not routinely appropriate
• CPVT + NSVT despite beta-blocker + flecainide: M(5–6)
• LQTS + asymptomatic + QTc >500ms + beta-blocker intolerant: M(6)

Section 6 — Comorbidities Modifying ICD Appropriateness

• Age ≥85 + NYHA II + LVEF ≤35%: M(5–6) — life expectancy and patient preference weigh heavily
• IV/illicit substance use disorder active: R(2) — device infection risk substantially elevated
• Dialysis-dependent ESRD + LVEF ≤35%: M(4–5) — high competing mortality; benefit signal smaller
• Frailty (severe) + LVEF ≤35%: M(4–5) — poor functional outcome and survival benefit uncertain
• NYHA IV, awaiting transplant, hemodynamically supported: A(7)
• NYHA IV, refractory HF, not transplant/LVAD candidate: R(2)

Section 7 — ICD Generator Replacement

• Prior ICD indication still valid + LVEF unchanged ≤35%: A(8)
• Prior ICD indication + LVEF improved 36–49%: M(6)
• LVEF now ≥50% (normalised), no documented VA: M(4)
• Prior documented sustained VA regardless of current LVEF: A(8–9) — prior VA is an independent indication
• Patient with renal failure progressing, or new severe comorbidity reducing life expectancy: M(4–5)

Section 8 — Subcutaneous ICD (S-ICD)

• Primary prevention, ischaemic or nonischaemic CM, LVEF ≤35%: A(7) — PRAETORIAN noninferior to TV-ICD for complications + inappropriate shocks; UNTOUCHED: 95.9% inappropriate shock-free at 18 months
• HCM primary prevention: A(7); ARVC: M(5) — needs ATP capability
• Congenital heart disease with venous obstruction or complex anatomy: A(8)
• ESRD on dialysis (avoiding transvenous leads): A(7)
• Sustained monomorphic VT requiring ATP: M(4–5) — S-ICD cannot pace-terminate; TV-ICD preferred
• S-ICD preferred when venous access impaired or infection risk high
• Dual-zone programming and SENSE algorithm substantially reduces inappropriate shocks

Section 9 — Cardiac Resynchronization Therapy (CRT)

• LVEF ≤35% + LBBB morphology + QRS ≥150ms + NYHA II–IV (sinus rhythm): A(9) — strongest evidence base (MADIT-CRT, RAFT, CARE-HF)
• LVEF ≤35% + LBBB + QRS 120–149ms + NYHA II–III: A(7)
• LVEF ≤35% + non-LBBB + QRS ≥150ms + NYHA III–IV: A(7); NYHA II: M(5)
• LVEF ≤35% + non-LBBB + QRS 120–149ms: M(4–5) — weak evidence base
• LVEF ≤35% + QRS <120ms (narrow QRS): R(1) — no benefit, ECHO-CRT and RethinQ showed harm/no benefit
• LVEF 36–50% + LBBB + QRS ≥150ms: M(4–6) — limited evidence; pacing-induced cardiomyopathy subgroup may benefit
• Atrial fibrillation + CRT indication: Reduces appropriateness by approximately 1 tier (A→M) unless AV junction ablation performed; AVJ ablation restores A(7–8)
• Right ventricular pacing-induced cardiomyopathy (LVEF decline ≥10% or LVEF <50%): A(7) for upgrade to CRT
• CRT upgrade from RV pacing >40% burden + LVEF ≤50%: A(7)

Section 10 — LVAD + ICD

• De novo ICD at time of LVAD implantation, primary prevention indication, no prior VA: M(4–6) — LVAD provides haemodynamic support; survival benefit of ICD on top of LVAD uncertain
• De novo CRT-D at LVAD implantation: R(2–3) — LV lead redundant with LVAD mechanical support
• Prior ICD + LVAD implantation: Continue device management; generator replacement A(7–8) if prior VA

Section 11 — Post-Cardiac Transplant ICD

• Cardiac allograft vasculopathy (CAV) with preserved LVEF: M(6)
• Rejection episode + LVEF ≤35%: A(7)
• SCD risk post-transplant is 4× higher than general population; standard primary prevention criteria often apply once ≥1 year post-transplant with stable allograft function

Section 12 — Cardiac Contractility Modulation (CCM)

• All CCM scenarios rated May Be Appropriate (M 4–5)
• Target population: LVEF 25–45%, QRS <130ms (not meeting CRT criteria), NYHA II–III, ≥3 months GDMT
• NYHA II + LVEF 25–45% + QRS <120ms: M(5)
• NYHA III + LVEF 25–45% + QRS <120ms: M(5)
• NYHA III + LVEF 25–45% + QRS 120–129ms: M(4)
• Mechanism: nonexcitatory pulses during refractory period enhance contractility without triggering AP
• FIX-HF-5C RCT: QoL and exercise capacity improvement; FDA-approved; no mortality benefit established
• CCM fills a gap for symptomatic HF patients with narrow QRS ineligible for CRT

Section 13 — Leadless Pacing

• AF + normal LVEF + anticipated pacing burden <40%: A(7) — single-chamber leadless (Micra-AV) appropriate
• Sinus rhythm + high-degree AVB + normal LVEF + <40% pacing: M(5) — dual-chamber leadless now available (EV-ICD/Aveir DDD) but longevity and cross-talk limitations still relevant
• LVEF ≤35% requiring pacing >40%: Leadless less preferred; M(4–5) — device longevity vs patient longevity and inability to upgrade easily are key limitations
• Pacemaker-dependent patients: R(2–3) for leadless unless specific indication (venous obstruction/prior device infection)
• Key concern: Device longevity (7–9 years); extraction risk; no lead-based ICD option from leadless device

Section 14 — Conduction System Pacing (CSP)

• HBP or LBBAP as alternative to RV pacing in high pacing burden (>40%): A(7) — physiological activation
• CSP-CRT (HBP/LBBAP replacing LV lead in CRT): M(5–6) — insufficient RCT data for higher rating
• LBBAP preferred over HBP at most centres given better electrical parameters, larger target, and lower threshold rise
• CSP rated lower than BVP-CRT until large randomized outcomes trials (PROTECT-HF, Left vs Left) report

Limitations of the Document

• AUC is expert consensus using modified Delphi — not a systematic evidence review; ratings may not account for all published evidence uniformly
• Many scenarios extrapolated from major trials (MADIT-II, DANISH, PARADIGM-HF) with different contemporary GDMT
• DANISH trial (NICM primary prevention) predates SGLT2i and sacubitril–valsartan; GDMT improvements may shift ICD NNT
• Genetic condition scenarios have limited RCT evidence — predominantly observational registries
• No patient-level outcome modelling for age ≥85 or comorbid populations; expert opinion dominant
• AUC does not account for shared decision-making nuances, patient preference, or quality-of-life trade-offs beyond what panel consensus captures
• Conduction system pacing section reflects rapidly evolving field with limited long-term outcome data

Key Concepts Mentioned

• concepts/Conduction-System-Pacing — Section 14 AUC ratings for HBP/LBBAP vs RV pacing and as CRT alternative
• entities/HFpEF — CCM fills gap for narrow-QRS HF with LVEF 25–45%
• concepts/VA-Risk-Stratification-DCM — NICM primary prevention ICD; LGE + LVEF 36–49% M(5–6)
• concepts/Sudden-Cardiac-Death — disease-specific ICD thresholds across all sections
• concepts/Arrhythmogenic-Cardiomyopathy — ARVC secondary/primary prevention ratings
• concepts/HCM-Risk-SCD — HCM ICD: ≥1 risk factor → A(8)

Key Entities Mentioned

• entities/ICD — primary subject; all sections
• entities/CRT — Section 9; evidence base and appropriateness ratings
• entities/S-ICD — Section 8; PRAETORIAN/UNTOUCHED evidence
• entities/CCM — Section 12; all May Be Appropriate; FDA-approved for narrow-QRS HF
• entities/HCM — ICD A(8) with ≥1 risk factor; S-ICD A(7)
• entities/ARVC — secondary prevention A(9); primary prevention A(7) with risk factors
• entities/LMNA — ICD A(7–8) at LVEF 35–45%
• entities/Heart-Failure — NICM ICD, CRT, CCM, LVAD+ICD scenarios
• entities/Atrial-Fibrillation — AF modifier reducing CRT appropriateness; leadless pacing A(7)

Wiki Pages Updated

• wiki/sources/icd-crt-auc-2025.md — created (this page)
• wiki/entities/ICD.md — created
• wiki/entities/CRT.md — created
• wiki/entities/S-ICD.md — created
• wiki/entities/CCM.md — created
• wiki/concepts/Conduction-System-Pacing.md — updated (AUC 2025 ratings added)
• wiki/sourceindex.md — updated
• wiki/wikiindex.md — updated