If I had to be another kind of doctor, I’d be a geriatrician. I enjoy taking care of older people. Older folks impress me because they got to be old. They survived, and more often than not, gained wisdom. I’m drawn to wisdom.
When I see an elderly patient referred to me for an arrhythmia, I worry most about making them worse. My imaginary friend says: “John, this guy made it to 80, don’t mess him up getting fancy.”
Sometimes it’s easy. The elder may be suffering with an SVT (supraventricular tachycardia), atrial flutter or heart block. Fixing those problems results in immediate improvement in quality of life. A win.
The ICD decision in the elderly is not so easy. In this case, you are considering exposing the elder to the risks of an ICD for a potential extension of life. But, by definition, an elder has already had an extension of life. The trade-offs with ICDs in this group are great: One is the risk of removing the ability to die painlessly. The second is the pain from a shock. Third, the extension of life, especially in the elderly with other conditions, may not be ideal. There are many more, but the idea is that the elderly are at higher risk of any sort of death, not just arrhythmic death. ICDs only improve lifespan in patients with a high risk of arrhythmic death and low risk of other deaths.
These factors make the decision to implant an ICD in an elderly patent a highly preference-sensitive one. The patient is the expert on what it most important to them.
This week, researchers from Ontario Canada published a new study in the journal of the American Heart Association, Circulation. The press release and headline declared that the elderly may benefit from an ICD as much as younger patients. I don’t think the data supported that.
I wrote about it over at theHeart.org. The title of the post is: Elderly patients considered for an ICD: Facing facts, mastering the obvious, and sharing the decision.