Doctoring ICD/Pacemaker

Cardiology and stewardship — New post up at Medscape|Cardiology

One of the definitions of the noun steward is a person whose responsibility it is to take care of something. Wikipedia calls stewardship an “ethic that embodies the responsible planning and management of resources.”

These apply well to cardiologists–who use powerful (and expensive) tools in the care of fellow humankind. The internal cardiac defibrillator, or ICD, is one such “big hammer.” The $30,000 device automatically terminates sudden cardiac death via internally delivered 750-volt internal shocks. These shocks usually prevent the patient from dying of that arrhythmia at that moment.

The cost of the ICD, however, is not just in dollars. The tradeoff means exposing the ICD patient to harm, such as surgery complications, infection, inappropriate (wide awake) shocks and the worst harm of all: a bad rather than good death.

Said another way, when used well the ICD extends life rather than prolongs death.

This is where stewardship comes in. Our job as cardiologists is to see the whole person rather than a person with a list of diseases. Too often, a patient with a weak heart (low ejection fraction) is told they “need” an ICD, or…and here is the catch…”they will die.”

You can see where I am going because I’ve been there before so many times. First, there’s the issue of using the verb need in the counsel of patients. Gosh, I hate that. Doctors don’t determine whether patients need invasive treatments, patients do. Then there is the issue of using the fear of death. Of course they will die. We all die. Treating death as optional lies at the root of our end-of-life humanitarian crisis.

Two recent studies in the Journal of the American College of Cardiology urge cardiologists to think hard about our role as stewards in the use of the ICD. One study evaluated the appropriateness of ICD-generator change and the other the utility of the six-minute-walk test in predicting ICD benefit.

The ICD generator change story is important because one in three ICDs are implanted as replacement devices for patients whose original device has reached battery depletion. (Approx battery life is 4-8 years.) Many factors combine to make the decision to replace an ICD different from the original implant decision. Mostly, it’s time. Patients with ICDs age, change their views and acquire other life-limiting diseases. And in many cases, as reported by University of Pennsylvania researchers, patients with ICDs actually improve their heart function so that their risk of death by arrhythmia diminishes. Now what should be done? Are ICDs life-long therapies?

The second study involved the use of walking ability (six-minute walk distance) as a means to predict ICD benefit. The role of functional capacity in determining ICD benefit is relevant because it speaks to the whole person rather than the person with a weak heart.

In the post on, which is now called Medscape|Cardiology, I describe the two studies and then explain why they provide a major opportunity for cardiologists to be stewards for both our patients and our profession.

I hope you want to read more. Here is the title and link: ICD Decision Making: An Opportunity for Stewardship


2 replies on “Cardiology and stewardship — New post up at Medscape|Cardiology”

The article and column talk about the possibility of an explantation instead of a generator change. Does explantation in that situation include removal of leads, which carries real risk after several years, or are the leads left in place, leaving the same high risk of tricuspid valve damage and an endocarditis risk that’s just been exacerbated by the extra procedure?

I mentioned that my husband was coerced into receiving an unnecessary pacemaker – twice – in a nasty malpractice cascade. He was promised an explantation, but then the rug was yanked out from under him. Instead of fighting, he decided to give up, stop the allegedly mandatory lifetime follow-up, and just live with the lifestyle restrictions the thing imposes and hope that it’s not erroneously pacing him into disaster. He’s had it for over three years and still has pain in the pocket and symptoms of post-traumatic stress. I wish he could get a complete explantation – if insurance would pay or if he could go abroad – but I also recognize that lead extraction is increasingly unsafe, and since the statute of limitations has expired we have no leverage to pressure anyone. I recognize you can’t give individual health advice online, but in general, is there any real hope for Americans in his situation to be liberated or are they better off just working to find acceptance?

By the way, from our experience I would sure tell anyone who is being coerced toward an ICD who has a job involving electrical equipment, enjoys any sport, etc., to ask very hard questions about what activities he will be expected to fear in future. I’ll never spar with my husband again, and his chiropractor won’t give him the inversion treatment that would be desirable for his back pain. You can’t even play golf for six months, and if you’ve already had lead-induced arrhythmias and you have reason to believe that your latest -ologist put the wires in by the most risky subclavian route, you may never dare to use your expensive weight bench again. If you can’t exercise because you’re disabled by procedures, your chances of challenging your doctor’s prophecies of doom by getting your heart in better shape are correspondingly lowered.

I know that you are not fond of these devices, but mine gives me the confidence to play tennis, cycle and hike solo. I just wish they could extend the battery life or make them rechargeable. 30k is a big expense every five years. And I got a magnetic doughnut with mine so I can turn it off if I ever get to the “end of life” scenario that you worry about.

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