Leading cardiovascular societies have unveiled an updated appropriate use criteria (AUC) document redefining clinical decision-making for cardiac implantable devices. The practice guideline entitled "ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing" was published online in the Journal of the American College of Cardiology.1 This 2025 update—12 years after the previous version2—integrates cutting-edge evidence and emerging technologies to guide the use of implantable cardioverter-defibrillators, cardiac resynchronization therapy, conduction system pacing, leadless pacing, and cardiac contractility modulation. 

The revised document now details 335 common clinical scenarios, each rated on a scale from 1 to 9: 

• Appropriate (7–9): Supported by robust clinical trial evidence or extensive clinical experience.
• May be appropriate (4–6): Reflecting nuanced scenarios where evidence is evolving or patient-specific factors may balance benefits.
• Rarely appropriate (1–3): Cases where data indicate potential harm or lack sufficient evidence to justify device implantation. 

This structured rating system allows clinicians to align patient care with the latest research and real-world practice. 

Since 2013, significant advancements in cardiovascular technology have emerged. The new AUC document now includes: 

• Emerging therapies: Expanded sections on conduction system pacing—specifically His-bundle and left bundle area pacing—alongside leadless pacing and cardiac contractility modulation.
• Complex patient populations: Updated guidelines for patients with heart failure, including those with left ventricular assist devices or post-cardiac transplantation, reflecting the growing complexity of device management.
• Enhanced risk stratification: In addition to traditional metrics such as left ventricular ejection fraction and the New York Heart Association class, the criteria now integrate electrophysiological factors, genetic predisposition, and patient symptoms, promoting a more personalized approach to therapy. 

The update results from a collaborative effort among eight major societies—including the American College of Cardiology, American Heart Association, and Heart Rhythm Society—that brought together cardiovascular medicine, electrophysiology, heart failure, and imaging expertise.  

The 2025 AUC update builds on the 2013 foundation by providing advanced tools and evidence to aid clinicians in device therapy decisions. With the evolving landscape of cardiovascular treatment, the update supports shared decision-making. This approach promotes personalized treatment plans that integrate device therapy with comprehensive heart failure, arrhythmias, and ischemic heart disease management. Additionally, the updated AUC serves as a guide for identifying evidence gaps, with scenarios rated "May be appropriate" indicating areas for further research. Ongoing studies and periodic updates will be crucial to maintain the effectiveness of device therapy in meeting individual patient needs. 

References 

1. Russo AM, Desai MY, Do MM, et al. ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR 2025 Appropriate Use Criteria for Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy, and Pacing. J Am Coll Cardiol. 2025:S0735-1097(24)10510-4. doi: 10.1016/j.jacc.2024.11.023. PMID: 39808105.
2. Russo AM, Stainback RF, Bailey SR, et al. CCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy: a report of the American College of Cardiology Foundation appropriate use criteria task force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Heart Rhythm. 2013;10(4):e11-58. doi: 10.1016/j.hrthm.2013.01.008. PMID: 23473952.