How to talk to patients about ICD choices Stephen Wilton ACC - - PowerPoint PPT Presentation

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How to talk to patients about ICD choices Stephen Wilton ACC - - PowerPoint PPT Presentation

Nov 01, 2023 171 likes •492 views

How to talk to patients about ICD choices Stephen Wilton ACC Rockies, Banff March 14, 2017 Disclosures Research Support Medtronic Canada, Boston Scientific Consulting/Honoraria Arca Biopharma, Boehringer-Ingelheim I do not implant

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How to talk to patients about ICD choices

Stephen Wilton ACC Rockies, Banff March 14, 2017

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Disclosures

Research Support

  • Medtronic Canada, Boston Scientific

Consulting/Honoraria

  • Arca Biopharma, Boehringer-Ingelheim

I do not implant CIEDs

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Objectives

  • Review Canadian 1ry prevention ICD Guidelines
  • Review knowledge gaps
  • Discuss effective risk communication principles
  • Discuss patient selection: roles of comorbidity, frailty, patient

preferences

  • List helpful resources
  • *CRT, Secondary prevention and special situations not

covered

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CCS ICD Guidelines 2016

Bennett, CJC, 2016

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CCS ICD Guidelines 2016

Bennett, CJC, 2016

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Evidence overview

  • 7 primary prevention trials (N=4,981, excl CABG, post-MI)
  • Pooled RRR for all cause mortality: 0.76
  • Pooled ARR for all cause mortality: 7.9%, NNT = 13

Limitations

  • Need to incorporate baseline risk, inter-patient variability
  • Generalizability

Nanthakumar, JACC, 2004, Betts, Europace, 2013

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RCT Evidence – SCD-HeFT

Bardy, NEJM, 2005

Placebo: 36% @ 5y ICD: 29% @ 5y Alive due to ICD: 7%

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Patient Perceptions of ICD benefits

Interviews of ICD recipients

Groarke, PACE, 2012

What is the purpose of the ICD? N=69 To improve breathing? 52% To improve pump function of the heart? 61% To prevent heart attack? 65% To reduce risk of suddenly stopping breathing? 48% To improve ability to exercise? 50% To terminate arrhythmia 0%

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Patient Perceptions of ICD benefits

Stewart, J Card Fail, 2010

Survey of 105 Primary prevention ICD recipients or ICD-eligible

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Tips for Effective Risk Communication

  • Use Quantitative rather than Qualitative descriptors
  • Present statistical info using Absolute, not Relative risk
  • Highlight incremental versus baseline risk
  • Use Pictographs to display risks and benefits

Lin and Fagerlin, Circ CV Outcome, 2014

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Data overview

Stevenson, LW, J Card Fail, 2006

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Patient Selection – Basic Principle

Risk of sudden death Risk of non-sudden death

5 Years

Challenge Enrich ICD population for sudden vs. non-sudden death

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Patient Selection – Role of Age

  • Pooled analysis of 5 RCTs
  • N=390 Age >75
  • Decreasing ICD benefit with

increasing age

Hess, Circ:Quality and Outcome, 2015

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Patient Selection – role of NYHA Class

Miller, CJC, 2015

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Patient Selection – Role of comorbidities

  • Individual patient meta-analysis (MADIT I&II, SCD-HeFT, DEFINITE)

Steinberg, JACC:HF, 2014

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Patient Selection – What about NICM?

Køber, NEJM, 2016 Golwala, Circ, 2017

DANISH

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Patient Selection – Role of Frailty

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Patient Selection – Role of Frailty

  • Decreased reserve & increased vulnerability to stressors
  • Overlap with, but independent of age and comorbidities
  • Slowness: 5m gait speed
  • Weakness: grip strength, time to stand from chair
  • Shrinking: weight loss, sarcopenia
  • Inactivity
  • Exhaustion
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Putting it together – Clinical Prediction Scores

  • Models to identify those likely to

die despite an ICD

  • Based on RCTs and registries
  • Seattle HF Model, Charlson

Comorbiditiy Index can be used SHOCKED (Bilchick, JACC, 2012)

  • Age ≥75
  • NYHA 3
  • AF
  • COPD
  • CKD
  • LVEF ≤ 20%
  • DM
  • C-stat = 0.75
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SHOCKED Score Nomogram - examples

  • 1. 76 yo male with ischemic CM, LVEF 28%, sinus rhythm,

NYHA Class 2, no other significant comorbidities

– Total points = 62, 4-year survival ~74%

  • 2. 76 yo male with ischemic CM, LVEF 15%, persistent AF,

CKD and DM

– Total points = 251, 4-year survival ~ 21%

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Shocks versus Death – Ontario ICD registry

  • N = 3,445 Primary prophylaxis ICD recipients
  • Competing risk models for ICD shock and all-cause death

Lee, Circ HF, 2015

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Shocks versus Death – Ontario ICD registry

Lee, Circ HF, 2015

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Clinical Prediction Scores – What could go wrong?

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Patient Selection

Risk of sudden death Risk of non-arrhythmic death

Risk of complications Risk of psychological distress Burden of Follow-up

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What influences patient’s ICD decisions?

Yuhas, PACE, 2012

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Patient Decision Aids

  • Summarize benefits, risks and alternatives of treatments
  • Pre-visit or in-visit models
  • Improve knowledge and decisional confidence
  • Best for elective decisions involving significant trade-offs
  • ICD Decision Aids
  • https://www.healthlinkbc.ca/health-topics/uf9848#uf10122
  • http://optiongrid.org/option-grids/grid-landing/43
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Option Grid ICD Decision Aid

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Option Grid ICD Decision Aid

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Option Grid ICD Decision Aid

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Objectives

  • Review Canadian 1ry prevention ICD Guidelines
  • Review knowledge gaps
  • Discuss effective risk communication principles
  • Discuss patient selection: roles of comorbidity, frailty,

patient preferences

  • List helpful resources
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Take Home Points

  • ICD decision-making can be complex
  • There is time, so take it

– Understand patient knowledge, goals, expectations – Communicate realistic benefit and risk information

  • Standardized, quantitative risk communication can help
  • Individualizing risk predictions has promise

– Need better tools