There is a patient attached to that implantable defibrillator

As a follow-up to my post on why patients with implantable defibrillators should have access to their device’s data, I am going to talk about what your physician looks for when a device is interrogated.  Many times this happens in silence or with few words, and some pushes of a button, when done in the office, and when done with remote patient management, is accomplished either automatically or with the patient pressing a transmission button.  Lengthy discussions or explanations are the exception and not the rule for most practices. And the paucity of verbal exchanges in association with the defibrillator interrogation creates anxiety in addition to not being accompanied by in many instances a discussion about clinical aspects of care: symptoms, the emotional components of being an ICD patient who anticipates or who has experienced device therapy, or a partner wondering about sexual activity.

What the ICD does not tell your provider:

  • What you were doing when you had an arrhythmia.
  • The status of your arteries or heart pumping function.
  • What medications you did or did not take.
  • Whether you are smoking or eating at McDonalds.
  • Your quality of life.

Old model ICDs told us that you received a shock or didn’t, and whether your battery was dead or not. Newer ones act as lifelong monitors, not only of heart rhythm, but of the functional status of the device itself, the leads or wires, and the connection between them.  If an arrhythmia called atrial fibrillation is detected and is prolonged, it might signal, even though it was not felt, that there is an increased risk of stroke, for which a recommendation might be made to start therapy with a blood thinning medication.

It is important to discuss at the time of your device interrogation, regardless of the process in which it is performed, any symptoms experienced even if they do not seem important or severe. A constant dialogue person to person is never substituted by technological exchanges of data. Medications might need to be adjusted to address issues of rhythm problems or other aspects of heart disease.

One issue which creates anxiety is the one regarding an ICD or wire which is under FDA advisory or recall.  A recall does not imply the device and/or lead problem requires surgery, and in most instances, this is the case. If a device or lead is under an FDA advisory, there are very sophisticated computer formulas which are in place in the system which might detect problems very early.  An advisory does not mean all the devices or leads of that model have a problem, just that the incidence is increased. Do not be afraid to ask your physician any questions regarding an advisory or recall.

Another discussion which needs to take place is what to do in an elderly patient when a terminal or complex illness is diagnosed (dementia, severe cancer, etc).  An ICD is a device usually implanted to prolong life.  Therefore, it must be addressed if end of life directives are discussed as well.  It is possible to program the defibrillator portion of the device off and leave the pacemaker portion if that is wished. There are professional guidelines available to providers about this very issue.

One thing I always emphasize is that on the other side of an ICD is a patient.  That is the focal point of care.  We do not treat devices, we treat patients. The technology is but one tool we use, and not the thread that holds the doctor-patient relationship together.

David Lee Scher is a former cardiologist and a consultant at DLS Healthcare Consulting, LLC.  He blogs at his self-titled site, David Lee Scher, MD.

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  • http://twitter.com/bobbetts bobbetts

    A brilliant and also comforting suggestion your article offers the patient.  Had I not discussed my severe fatigue and shortness of breath with @DoctorWes my interrogation may have been glossed over and the elongated QT time missed.  It wasn’t and CRT with a new device was implanted.  Gone was the AF, the fatigue and conditions of stage 3 CHF.

    • Anonymous

      Patients are their best advocates. They falsely believe they need to give the diagnosis to the doctor. They only need to describe what they feel. Osler, the Father of American medicine once said that the Patirnt will always give you the diagnosis.

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