Doctoring ICD/Pacemaker Knowledge

The beeping shocker vest: The antithesis of common sense…

Unfortunately, there are therapies in medical practice which become worse than the disease they are intended to treat.  Us heart specialists are not immune from these transformative therapies.

Even dumber than the ineffective rhythm drug that comes highly recommended by academia, is the LifeVest: a wearable automatic shock collar for people.

He was in his early seventies, having just retired from a life of community service in his small town.  His wife was at his side. The speed with which I knew we were going to get along was striking.  He and his wife exuded a genuine warmth and kindness that was palpable.  He must have known I would tell him he never had to wear the vest again.

Immediately after hearing his story, I offered first, “no more vest–ever.”

The relief on his face was obvious.  His eyes beamed with approval.  It had been awful wearing the vest in recent weeks.  It was heavy and complex. The incessant beeps frightened he and his wife. They were always afraid. Life stopped.  They were prisoners in their own home.

It all started with the gradual onset of shortness of breath and puffy ankles. The left bundle branch block and abnormal ultrasound prompted his cardiologist to perform a heart catheterization.  His arteries were clear, but the heart muscle was weak; it was a cardiomyopathy.  One cannot exclude an exotic viral cause, but many times more likely was his lifelong high blood pressure.

The shocking-vest representative from Zoll corporation–as he had tried at my office–must have had more success with this patient’s doctor. The recommendation for a weakened heart included living life with the shocking vest.  A protection from the theoretical yet-to-happen sudden arrhythmia.

It is true that SCD is a leading killer, and that a weakened heart increases the risk of arrhythmia, like a teenager is at higher risk driving an automobile. Guidelines say that in some cases, we should wait to implant a permanent ICD for months after the original diagnosis.  Guidelines rightly acknowledge that many cardiomyopathies, especially those in the young patient without obvious causes–unlike in this case of lifelong high blood pressure–will resolve spontaneously.

Not only was this patient tormented by the shackle-like vest, but he actually had an arrest at home.  The vest was useless, because at the time of the event he wasn’t wearing it.  He told me that the shower was his favorite time of day; he was free from the vest.  He collapsed minutes after a shower.  His wife called the paramedics and they saved him.

It turned out the arrest was related to a high potassium value.  He had urinary retention, kidney failure and high potassium had stopped his heart. A week later the kidneys had normalized after the urologist relieved the obstruction.  However circuitous, it was an enlarged prostate that delivered him to me.

His heart was still weak, and the left bundle branch still there. Even though the arrest was secondary to a non-cardiac cause, the right thing to do was obvious, regardless of any guideline-mandated timeline.  If guidelines were universally applicable, computers could care for patients.

There are no more suitable patients for CRT (bi-ventricular) device implantation than the symptomatic patient with non-ischemic cardiomyopathy and LBBB.

The vest is gone.  His breathing is better. The ECG-narrowing three lead device is functioning beautifully.  His grin and look of life is many times more gratifying than any financial compensation.

I have yet to discover any better example of a treatment being worse than the disease, than the pavlovian LifeVest.  Ineffective, obtrusive, enslaving and strikingly devoid of any prospective comparative data sums up my take on the LifeVest.  It sits at the opposite bipole from common sense.

Minimizing death from sudden arrhythmia is an important goal.  It is my life’s work.   However, we cannot prevent all sudden death, and our efforts to do so should not eliminate the living of life.  We must accept the inherent risk in life itself, as we do driving a car on a two lane road in suburbia.

Sometimes, implanting an ICD should wait a short period of time, but until there is overwhelming evidence from prospective trials showing benefit to the beeping shocker vest, I say wait the short time, or find a reason that the patient should have the permanent ICD now.

Practice medicine, accept some risk.  Let patients live life.

Do onto patients as to what you would do to yourself.


One reply on “The beeping shocker vest: The antithesis of common sense…”

I reviewed the 2009 HF guidelines.

From Table 3 of the 2009 guidelines (this is a revision to the 2005 indication)
Class I indication

9. Implantable cardioverter-defibrillator therapy is
recommended for primary prevention of sudden
cardiac death to reduce total mortality in patients with
non-ischemic dilated cardiomyopathy or ischemic heart
disease at least 40 days post-MI, a LVEF less than or
equal to 35%, and NYHA functional class II or III
symptoms while receiving chronic optimal medical
therapy, and who have reasonable expectation of
survival with a good functional status for more than 1
year (40,93–99). (Level of Evidence: A)

I have had some insurers call to discuss implanting devices earlier than CMS approved timeframe based on these guidelines. the rationale is that the patients will get the device anyway and the beeping vest is expensive.

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