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Study: Implanted Cardiac Defibrillators Overused

Researchers Say Some Patients Who Get ICDs May Not Meet the Criteria in Guidelines

Specialists vs. Non-Specialists

When researchers further checked the data, they discovered that whether or not a device was implanted against guidelines could depend on the kind of doctor who was performing the procedure.

Electrophysiologists, doctors who specialize in treating problems with the heart’s rhythm, were less likely to implant devices in patients who didn’t meet recommendations than non-specialist cardiologists or thoracic surgeons.

However, study author Al-Khatib says the reasons why patients get the devices outside clinical guidelines are likely to be multifaceted.

“There may be a lack of awareness about the guidelines or a lack of knowledge, particularly among non-specialists,” Al-Khatib says, “or, at the end of the day, physicians may not agree with the guidelines.”

John Mandrola, MD, an electrophysiologist at Baptist Hospital East who blogs about health care,  says, “Early on there were many cardiologists implanting devices because they were easy to do, well reimbursed, and the tone of the times was that ICDs were underused. Since ICD scrutiny is increased, doctors have still continued to use them inappropriately because they falsely believe in their benefits, and minimize the risks. They are trained to fight for life and perhaps uncomfortable talking with patients about end-of-life choices. When you deal with death -- the outcome of malignant arrhythmia -- it gets emotional.  For a lot of cardiologists, death is the absolute enemy. These emotional overtones can affect science-based acceptance of ICD indications." 

Risks of Improper Implantation

To attain maximal benefit, ICDs must be implanted in the right patients at the right time. For patients who get an ICD within 40 days of a heart attack, within 90 days of coronary artery bypass surgery, or in the earliest stages of heart failure, the risk is that the device may be implanted too early, before the heart has had a chance to recover. So some of these individuals may not benefit from implantation because their hearts ultimately heal and the device is never actually needed.  

On the other end of the spectrum, patients in the most advanced stage of heart failure may be subjected to repeated, painful shocks without any lengthening of life.

“These are superb, lifesaving devices, but they do have downsides,” Kadish says.

Mandrola says patients who are told they need a defibrillator should make sure they understand why they need one and how the device could affect them. “Ask, ‘What are the benefits? What are the risks?’ And be sure the doctor knows your expectations about life expectancy and quality of life. The shocks are 750 volts, and they’re painful.”

Mandrola also recommends seeking out another opinion if you’re not sure you want an ICD. “Two doctors look at the same thing differently.”

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