Derek T. Connelly Consultant Cardiologist Glasgow Royal Infirmary - - PowerPoint PPT Presentation

Derek T. Connelly

Consultant Cardiologist Glasgow Royal Infirmary and West of Scotland Heart & Lung Centre, Golden Jubilee National Hospital Honorary Clinical Associate Professor, University of Glasgow

S J Connolly, Eur Heart J 2000; 21:2071-8

Meta-analysis - ICD v Amiodarone

MADIT II Results

Moss et al New Engl J Med 2002; 346: 877-883

SCD-HeFT: Mortality by Intention-to-Treat

0.4 0.3 0.2 0.1 Mortality 6 12 18 24 30 36 42 48 54 60 Months of follow-up Amiodarone ICD Therapy Placebo HR 97.5% Cl P-Value Amiodarone vs. Placebo 1.06 0.86, 1.30 0.529 ICD Therapy vs. Placebo 0.77 0.62, 0.96 0.007

Bardy GH et al New Engl J Med 2005; 352: 225-37

Swedberg K et al Eur Heart J 1999; 20: 136-9

Emergency: Magnet

Deactivation: challenges

 Availability of magnet for inhibition of

tachycardia therapies

 Availability of programmer for patients

being cared for at home or in hospice

 Delivery of service: who takes the

programmer to the patient’s home?

 Limited programming options for

patients who might want certain therapies programmed

Functions of the ICD

 Bradycardia pacing (including post

shock)

 (Cardiac resynchronisation pacing)  Detection of arrhythmias  (Detection of worsening heart failure)  Anti-tachycardia pacing to terminate VT  Cardioversion and defibrillation of VT

and VF

Palliative Care and ICDs

 There is nothing “palliative” about the

shock function of an ICD

 Shocks are painful  Shocks are generally infrequent  Fear of shocks* may be more of a

problem than shocks themselves

 *or fear of multiple shocks

Defibrillation and pain

 Shock lasts 10 ms  Pain lasts a few seconds  The average ICD patient gets less than

• ne shock per year

 1 year = 31.5 million seconds  1 month = approx 2.5 million seconds  If a patient is getting 1 shock per month,

pain is present 0.0001% of the time

Sudden Death During Ambulatory ECG Monitoring

 157 cases from 10 published studies  98 (62.4%) VTVF  13 (8.3%) primary VF  20 (12.7%) torsades de pointes

 Often in patients without structural heart

disease, being treated with antiarrhythmic drugs

 26 (16%) bradycardiaasystole  Very few had ischaemic ST-T changes

Bayes de Luna, Coumel & Leclerq Am Heart J 1989; 117: 151-9

Characteristics of Patients Who Die with Heart Failure and Low EF

 160 patients with LVEF  35% died in FU at

Brigham and Women’s Hospital, Boston, between Jan 1st 2000 and October 2003

 In 6 months prior to death 93% had NYHA

III/ IV symptoms

 Death was considered sudden in only 21%

• f cases

 Often bradycardia / PEA rather than VT/VF

 37% had ICDs (mostly switched off)

Teuteberg JJ et al. J Cardiac Failure 2006;12:47-53

If I had an ICD…

and a terminal illness

 I still wouldn’t want to die suddenly  I wouldn’t want CPR … but still might want

my ICD to be active

 I would still want antitachycardia pacing for

VT

 I might still put up with the occasional

shock …

 But I wouldn’t want to have multiple shocks

if the first 1-2 shocks didn’t work...

 And I wouldn’t want to have several shocks

in one day

If I had an ICD…

and a terminal illness

 I still wouldn’t want to die suddenly  I wouldn’t want CPR … but still might want

my ICD to be active

 I would still want antitachycardia pacing for

VT

 I might still put up with the occasional

shock …

 But I wouldn’t want to have multiple shocks

if the first 1-2 shocks didn’t work...

 And I wouldn’t want to have several shocks

in one day These are not programmable options!

Kramer DB et al N Engl J Med 2012; 366: 291-3

ICD replacement

“There are several important opportunities for – and obstacles to – making ICD replacement a more deliberate process”

 Clinical data must be re-evaluated

 ? deterioration (or improvement) in health

 Patients’ experiences of device therapy  Patients’ changes in values /

preferences

Kramer DB et al N Engl J Med 2012; 366: 291-3

Kramer DB et al N Engl J Med 2012; 366: 291-3

Case Study

 CW

♂ DoB 23/9/45

 ICD implant 2005 for sustained VT  Moderate LVSD; NYHA Class I  Occasional episodes of VT requiring

antitachycardia pacing; no shocks

 Device now approaching end of battery life  Severe stroke 10 months ago; in nursing

home; wheelchair-bound; aphasic

 Wife does not accept that his disability is

permanent; she wants his device to be replaced

Case study

 Rev PJGB

♂ DoB 6/2/31

 Previous anterior MI, LBBB (QRS width

150ms); previous CABG; LVEF 30%

 Primary prevention ICD 2007

 No events, no therapies since implant

 Recent worsening heart failure  ICD nearing end of battery life

 Replace with ICD?  Replace with CRT-defibrillator?  Replace with CRT-pacemaker?

Pettit SJ et al BMJ Supportive & Palliative Care 2012; 2: 94-97

When to deactivate: Literature review

 Review of records of 63 patients who

died with an ICD in situ

 Terminal diagnosis leading to ICD

inactivation in 32%

 For patients with active ICDs, 21%

received a shock within their final month

 For patients with deactivated ICDs, 15%

had received a shock within their final month (prior to deactivation)

Lewis et al Am J Med 2006; 119: 892

 Questionnaire to relatives of 100

patients who died with an ICD in situ

 27 patients received ICD shocks in their

last month of life

 21 of these had “DNR” orders

 8 patients received shocks within their

last minutes of life

Goldstein et al Ann Intern Med 2004; 141: 835

When should ICD deactivation be discussed?

 ESC

 When it is clinically obvious that a patient is

about to die

 When a DNR order is in force  When impairment of QOL is such that

sudden death might be considered a relief

 British Heart Foundation

 When markers of poor prognosis in

advanced heart failure are present

Pettit et al 2012

When should ICD deactivation be discussed?

HRS Expert Consensus Statement

 Central role of the patient in deciding when their ICD

should be deactivated

 Counselling should be an ongoing process, starting

pre-implant and continuing as patient’s health changes

 Deactivation discussion should be prompted by  Multiple ICD shocks  Repeated hospitalisation  DNR orders  “end of life”  Patients decision should be supported, even if it

sems illogical to the physician

Pettit et al 2012

When is ICD deactivation discussed?

EHRA survey (2010):

 Only 4% of cardiologists discussed

deactivation pre-implant

 Onlu 11% were regularly involved in

discussions about deactivation

 Only 4% gave written info to patients about

deactivation Survey of relatives of ICD patients

 Deactivation discussed in only 27% of cases

 75% in last days of life  22% in last hours of life  4% in last minutes of life

Pettit et al 2012

ICD deactivation in hospices

 Survey of 900 hospices in USA (2010)  40% of hospices had at least one patient

who had experienced multiple shocks in the preceding year

 42% of patients had ICD deactivated

while receiving hospice care

 Only 10% of hospices had policies that

addressed deactivation at end of life

Goldstein et al Ann Intern Med 2010; 15: 296

Pettit SJ et al BMJ Supportive & Palliative Care 2012; 2: 94-97

ICDs: End-of-life issues

 No “evidence base”  Difficult to discuss these issues pre-implant (unless

patient / relative initiates discussion)

 Should be discussed openly and sensitively when any

crisis or deterioration occurs

 Multiple shocks  Deteriorating heart failure  Concomitant life-threatening illness, e.g. malignancy, renal

failure, stroke

 Should be mentioned routinely in booklets / website info

that is made available to patients

 In the UK, patient info is available from the British Heart

Foundation (www.bhf.org.uk ) and the Arrhythmia Alliance (www.Heartrhythmcharity.org.uk)



No guidelines



No evidence!



Prognostication in heart failure is difficult which makes the timing of device deactivation uncertain



Emotive subject requiring advanced communication skills



Lack of education

 Healthcare professionals – considering deactivation at

the appropriate time

 Patients concern that they will die immediately



Ethical issues

Why is deactivation so difficult to discuss?

When I die, I want to go quickly in my sleep, like my grandfather …. not screaming in terror like the passengers in his car

Conclusions

 All patients want to avoid undue

suffering at time of death

 BUT many patients want to avoid

sudden death!

 Even at an advanced stage in their condition  ICD patients may be a “self-selected” group

 Death by VT/VF storm is highly unusual  The wishes and preferences of the

patient are of the utmost importance

Conclusions

 Deactivation should be discussed early

 And again at appropriate points in the patient’s

illness

 Deactivation should be performed late?

 At a time when the patient wants it

 Deactivation should be an available option in

home or hospice

 Further research needed regarding therapies

that patients might find acceptable close to end of life

 Dialogue needed with manufacturers

regarding programming options at end of life