Every year about 100,000 implantable cardioverter-defibrillators (ICDs) are received by patients with life-threatening heart arrhythmias. About a quarter of those are replacements because of a depleted battery, many of which may be unnecessary.
Cardiologists argue that the time has come to offer reevaluations that focus on both clinical and ethical aspects for patients receiving replacements.
Some patients may no longer require the device, while others may opt to skip it to ensure they are comfortable when they are faced with end of life decisions.
Dr. Daniel B. Kramer, a cardiac electrophysiology fellow at Beth Israel Deaconess Medical Center and a clinical fellow in medicine at Harvard Medical School, said that such evaluations are overdue, and urged that patients and doctors move beyond the view that the medical device was designed as a lifelong therapy.
“Some patients may elect to keep these devices for the rest of their lives,” Dr. Kramer said. “But for others, the risks associated with replacing the device may outweigh any expected benefit.
We really need to make decisions on an individual basis.”
The devices are similar to pacemakers, and are implanted into the chest with a wire that runs to the heart. ICDs offer life-saving shocks of electricity to the heart when a potentially life-threatening heart rhythm is detected.
They are commonly implanted in patients with heart arrhythmias, such as atrial fibrillation, who are considered at risk for sudden cardiac death.
Dr. Kramer said that patients should receive a careful assessment similar to the one received before initial implantation of the device before a replacement. During that evaluation he said that patients' experiences with the ICD should be considered including receiving inappropriate shocks, their values and their preferences for end of life care.
He also suggested that patients have early conversations with family members about future replacement of the device, and that doctors who implant the device take the lead in educating primary care providers, cardiologists and others involved in patient care regarding the appropriateness of replacement.
Physician coordination is especially important since numerous specialists often coordinate the care of one patient and there may be confusion about who is ultimately responsible for discussions and decisions regarding ICD replacement.
Dr. Kramer also urged additional research, which he said could help better educate both patients and doctors about the appropriateness of ICD replacement.
The statement will be published in the Jan. 26 edition of the New England Journal of Medicine.