September 8th, 2011
When Is the Patient “Too Old” for an ICD?
An 86-year-old man presents to you for the first time with lightheadedness and increasing dyspnea on exertion, which he reports experiencing for the past 4 months. He has a history of coronary artery disease requiring 3-vessel bypass, dyslipidemia, hypertension, and chronic lymphocytic leukemia (CLL) that has been stable for many years.
His vital signs upon presentation are as follows: blood pressure, 110/80 mm Hg; heart rate, 35 bpm; afebrile; oxygen saturation of 98% on room air. His physical exam is significant for a 2/6 holosystolic murmur at the apex. He has no evidence of jugular venous pressure elevation, third-heart sound, rales, hepatosplenomegaly, or lower-extremity edema. ECG reveals sinus bradycardia at 35 bpm, a first-degree atrioventricular block, and a left bundle-branch block with a QRS duration of 160 ms. Lab tests show a creatinine level of 1.5 mg/dL and hematocrit of 30%.
A transthoracic echocardiogram reveals an LV ejection fraction of 30%. Records from the patient’s previous cardiologist document an LVEF of 30% more than 1 year ago. The patient has been on a stable regimen of an ACE inhibitor, furosemide, aspirin, and a statin. He was taking a beta-blocker for many years until 2 weeks back, when his primary care physician took him off the medication “due to slow heart rate.” The patient denies a history of syncope or cardiac arrest.
The patient lives alone, but his daughter visits him weekly and prepares food that lasts the entire week. His mobility is limited; at most he walks to a store down the street. He and his family want “everything done.” When questioned about the patient’s life expectancy with CLL, his oncologist says, “Your guess is as good as mine.”
- Would you consider pacemaker/ICD therapy for this patient? If so, would you suggest cardiac resynchronization therapy (or CRT with defibrillator)?
- What aspects of the patient’s clinical profile would influence your decision? How would you approach the conversation about an implanted device?
- How important should age be in choosing an expensive therapy such as an ICD? Should the decision be left to the patient and his family or to the caring physician?
- If an ICD is chosen, would you discuss the option of turning it off with the patient and his family?
James Fang, MD
September 29, 2011
This elderly man has symptomatic systolic heart failure from chronotropic incompetence and electromechanical dyssynchrony (e.g., wide left bundle-branch block) despite medical therapy. Pacing and cardiac resynchronization therapy (CRT) should be offered in this situation, given that there is reasonable evidence (although extrapolated from randomized trials involving patients younger than 70) to suggest biventricular pacing would enhance his quality of life by improving both the chronotropic incompetence and the dyssynchrony. Although the patient has chronic lymphocytic leukemia, it appears to be clinically stable (indeed, stable CLL can persist for years).
However, the evidence is modest that octogenarians, specifically, derive a clinically relevant improvement in overall survival with ICD therapy. The patient should be given the alternative of CRT without ICD, although that option is rarely offered in the U.S. The patient and his family need to know that concomitant ICD therapy will not improve his quality of life and could potentially make it worse, as the chance of receiving inappropriate shocks (e.g., from rapid atrial arrhythmias) is increased.
In ICD trials, the survival curves took at least one year to separate, and it is not known when (or if) this separation occurs in octogenarians. Notably, subsequent survival following an appropriate ICD shock is related to heart failure, which will not improve with ICD therapy alone. Thus, patients should be counseled that ICD therapy will simply change the mode of their ultimate demise from sudden death (which many people prefer) to an insidious decline in health, functional capacity, and loss of independence that accompany chronic heart failure.
Finally, patients and families should clearly understand that “turning off” the ICD is not tantamount to “turning the patient off.” Rather, it is an inactivation of an electrical discharge that would interfere with the peace and dignity of end of life when it inevitably comes.
Tariq Ahmad, MD, MPH
October 10, 2011
After long discussions among the patient, his family, and the cardiologists, spanning several outpatient clinic visits, a decision was made to implant a CRT device with ICD capabilities. Although it was believed that the patient would be likely to benefit from pacing and cardiac resynchronization, the decision regarding an ICD was more difficult. After input from the oncologist, the patient’s life expectancy was predicted to be at least 1 year. The patient and his family were told about the risks versus the benefits of an ICD, and they elected in favor of it. They were also heavily influenced by input from a family friend whose ICD had apparently “saved his life many times.”
The patient was brought in as an outpatient, the device was implanted without complications, and he was discharged the next day. He was seen in the EP device clinic 3 months after discharge and, according to the clinic note, appeared to “have more energy.” He was also seen in the heart-failure clinic, where he reiterated his improved HF symptoms. However, objective assessments of his functionality, such as peak VO2 testing, have not been performed. Also, discussions about turning the ICD off under certain clinical scenarios have not been broached.