‘Reassess patients’ before replacing ICDs
MedWire News: Not all individuals with an implantable cardioverter-defibrillator (ICD) should receive a new generator when the device's power reserve is running low, its leads become defective, or its system infected, say authors.
"From both patient and societal perspectives, the expense and uncertainty of ICD therapy argue for a more considered and nuanced approach to generator replacement," write Daniel Kramer (Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA) and team in the New England Journal of Medicine.
They say that there are both opportunities for and obstacles to making ICD replacement "a more deliberative process."
First, Kramer and team recommend that a comprehensive medical evaluation should occur before ICD replacement, integrating active communication between the implanting physician and primary care physicians, as well as other specialists involved in each patient's care.
Second, they say that patient preferences, past experiences - such as frequent inappropriate shocks - and advance care planning should be "explicitly included in decision making."
The authors advise that advance care planning is revisited, and patients educated about the chances of device deactivation at the time of potential ICD replacement.
On a larger scale, they write, a multidisciplinary task force should be created to establish guidelines regarding the clinical, ethical, and logistic aspects of ICD replacement.
And, going forward, Kramer and team say that prospective studies should be conducted among patients at high or low risk for sudden death who are eligible for ICD replacement, to identify populations that are unlikely to benefit from therapy.
"We propose that physicians who implant ICDs take the lead in engaging and educating primary care physicians, general cardiologists, and other specialists regarding the appropriateness of ICD replacement for individual patients," write the authors.
They conclude: "It is time for a change in our approach to this common, costly, and complex clinical decision."
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By Piriya Mahendra