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ICDs: Analyzing Patient Perception & Physician Communication

ICDs: Analyzing Patient Perception & Physician Communication

Implantable cardioverter-defibrillators (ICDs) have changed the way patients with cardiac arrhythmias are evaluated and treated. Asymptomatic patients often receive ICDs as part of a primary prevention strategy, but there is potential for post-implantation complications, most notably anxiety and psychosocial changes. In addition, ICD recipients are typically older and have comorbidities that serve as competing risks for mortality. Primary prevention strategies are indicated for patients who have not had a sudden death event or symptoms of life-threatening arrhythmias. In secondary prevention, patients have already experienced life-threatening events. Survival benefits are more likely to occur when ICDs are implanted for secon-dary rather than primary prevention. An important problem, however, is that currently available screening modalities to identify patients at risk for sudden death are lacking. “Making the decision to get an ICD is clearly a life-changing event for patients,” explains Paul J. Hauptman, MD. “Physicians need to explicitly discuss the benefits of these devices with patients and also educate them about risks beyond those of the implantation procedure itself.” Few studies, however, have addressed the information exchange between physicians and patients on pertinent issues with ICDs. These include discussions on the risks and benefits as well as potential consequences for quality of life (QOL). Exploring Information Exchange on ICDs Dr. Hauptman and colleagues had a study published in JAMA Internal Medicine that examined patient–physician communication at the time decisions were made to implant ICDs. Focus groups with recipients of ICDs were conducted to address the nature of pre-implantation discussions. The content and style of communication from cardiologists was observed when they met with standardized patients—people who were trained to act as...
Updated Guidelines for Heart Failure

Updated Guidelines for Heart Failure

Recently, the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) jointly released an expanded clinical practice guideline for the management of patients with heart failure (HF). The update, published in the Journal of the American College of Cardiology was designed to assist clinicians in selecting the best management strategies for patients. “The guideline updates definitions and classifications for HF, increases the emphasis on patient-centric outcomes, and introduces ‘guideline- directed medical therapy’ (GDMT),” explains Clyde W. Yancy, MD, MSc, FACC, who chaired the ACCF/AHA writing committee. Descriptions & Classifications of Heart Failure The ACCF/AHA guideline update provides a more focused approach on dilated cardiomyopathies and the appropriate evaluation of patients. This includes family and genetic screening and counseling. “The guidelines once again endorse four stages of disease progression: Stages A thru D,” explains Dr. Yancy. “Stage A patients are those with positive risk factors, whereas Stage B patients have existing but still asymptomatic left ventricular function.” “The expectations are highest for hospitalized patients with HF because of their vast resource consumption from initial admissions to subsequent readmissions.” Stage C is the classic patient with congestive HF, but importantly, Dr. Yancy says this patient group is now well dichotomized as having HF with reduced ejection fraction (EF) or HF with preserved EF. “Best therapies are aligned with each stage, specifically risk factor modification, pre-emptive medical and device therapies for asymptomatic left ventricular dysfunction, and classic evidence-based therapies for symptomatic HF patients with reduced EF,” he says. “The guidelines also provide a treatment algorithm for Stage C HF patients with reduced EF [Figure]. The algorithm, known as GDMT, can...
Improving Survival After In-Hospital Cardiac Arrest

Improving Survival After In-Hospital Cardiac Arrest

According to the American Heart Association (AHA), more than 200,000 adults and 6,000 children have in-hospital cardiac arrests (IHCAs) each year, and survival has remained relatively unchanged for decades. Research shows that only about one-quarter of IHCA patients survive to hospital discharge. “IHCA has not received the same level of focused research as out-of-hospital cardiac arrest (OHCA),” says Laurie J. Morrison, MD, MSc. “There are many gaps in science, policy, and institutional application and accountability for the care of IHCA patients.” Recently, the AHA released a consensus statement on strategies for improving survival after IHCA. Published in an issue of Circulation, the scientific statement is organized into four sections, based on scientific evidence from IHCA studies or reasonable extrapolation from the literature on OHCA. These include: 1) epidemiology, 2) best practices, 3) culture change and standardized reporting and benchmarking, and 4) conclusions and recommendations. “The consensus statement on IHCA gives healthcare providers, clinical leaders, administrators, regulators, and policymakers an overview of the various issues related to reporting, planning, and performing best practices for IHCA,” says Dr. Morrison, who was lead author of the AHA’s scientific statement. “It also documents what is known and should be applied to ongoing care and what is unknown about IHCA and should be researched to advance care.” Gathering Reliable Data on In-Hospital Cardiac Arrest According to the AHA, there is great variation across the country in how IHCAs are defined and counted and whether or not they are reported annually. “A serious obstacle to providing better care for IHCAs is the inability to gather reliable data,” says Dr. Morrison. “We must be able to...
Devices for Cardiac Rhythm Abnormalities: A Guideline Update

Devices for Cardiac Rhythm Abnormalities: A Guideline Update

According to recent estimates, about 400,000 pacemakers and implantable cardioverter defibrillators (ICDs) are surgically implanted each year in the United States. In 2008, the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Rhythm Society (HRS) released guidelines for using device therapy to manage cardiac rhythm abnormalities. Since the release of the 2008 guidelines, many clinical research advances relating to device-based therapies have emerged, says Andrew E. Epstein, MD, FAHA, FACC, FHRS. “In an effort to help clinicians keep pace with these advances, the ACCF, AHA, and HRS jointly released updated guidelines in 2012 for the use of device-based therapy in treating heart rhythm disorders. The guidelines can help in clinical decision making in most circumstances.” The 2012 update writing group included experts in device therapy, cardiovascular care, internal medicine, cardiovascular surgery, and pediatric and adult electrophysiology. The guidelines were also developed in collaboration with the American Association for Thoracic Surgery, Heart Failure Society of America, and Society of Thoracic Surgeons. Building on Earlier Cardiac Device Guidelines For the 2012 update, the writing group began by reviewing the 2008 recommendations. The latter are largely unchanged for standard pacing and ICD indications. However, given new data on cardiac resynchronization therapy (CRT), the 2008 guidelines were updated with CRT as its focus, especially with regard to expanding indications for this treatment (Figure 1). “CRT can significantly improve quality and quantity of life by delaying or avoiding worsening heart failure.” —Andrew E. Epstein, MD, FAHA, FACC, FHRS “Despite our improvements in managing patients with device-based therapies, it can still be challenging for physicians to select patients in whom...

Exploring Variances in Dual-Chamber ICD Use

Each year in the United States, approximately 140,000 implantable cardioverter-defibrillators (ICDs) are implanted in cardiac patients. Physicians often face challenges when working with patients to decide whether it’s best to use a single- or dual-chamber device. Some patients have a clear indication for a dual-chamber device because they have an indication for a pacemaker. For patients without an indication for a pacemaker, the decision is much less clear. The potential benefits of dual-chamber devices remain to be proven, and they may have more complications. Clinical trial data to guide physicians on which option to choose have been lacking. Currently, nearly two-thirds of patients undergoing ICD implantation for primary prevention receive dual-chamber devices. Variations in Dual-Chamber ICD Use In a study published in the April 23, 2012 Archives of Internal Medicine, my colleagues and I set out to explore hospital-level variation in the use of dual-chamber ICDs across the U.S. Using the Medicare-mandated National Cardiovascular Data Registry (NCDR) ICD registry, we looked at 87,115 patients from 2006 to 2009 receiving an ICD as primary prevention without a documented indication for a pacemaker. We only wanted to analyze patients for whom it wasn’t clear whether a single- or dual-chamber ICD was the appropriate choice. Of these patients, about 58% received a dual-chamber ICD. More importantly, use of each ICD type varied significantly by hospital and by physician. In some hospitals and with some physicians, 100% of patients without a clear indication for a dual-chamber ICD received such a device. At other hospitals and with other physicians, 0% of these patients received a dual-chamber ICD. “Differences in the local culture and practice...
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