December 18th, 2013
Doc, Do I Really Need a New Battery?
Tariq Ahmad, MD, MPH and James Fang, MD
A 45-year-old man with nonischemic cardiomyopathy, diagnosed 8 years ago, presents for annual follow-up. A transthoracic echocardiogram (TTE), taken 3 years ago, showed an LV ejection fraction of 25%. Since then, the patient has improved a great deal and now has barely any signs or symptoms of heart failure. Repeat TTE right before the current visit showed an LVEF of 50% and no significant abnormal findings.
An electrophysiologist who saw the patient a week before his current visit noted that his implantable cardioverter-defibrillator (ICD), which was placed 6 years ago but has never fired, is near the end of its life and needs a new battery. The battery replacement is scheduled for 1 month from now, but the patient is unsure whether to bother getting a new battery. He notes that his heart function is close to normal and wants to know if he should still take his heart failure medications (metoprolol, lisinopril, and spironolactone).
What would you advise this patient — and why?
1. Replace the ICD battery; keep taking the heart failure medications.
2. Do not replace the battery; keep taking the heart failure medications.
3. Do not replace the battery; discontinue the heart failure medications.
4. Another option
RESPONSE: December 22, 2013
James Fang, MD
I recommend option 1: Replace the ICD battery and keep taking the heart failure medications. Although the improvement in ventricular function is dramatic, an LVEF of 50% is, in fact, not normal. Moreover, the case makes no mention of ventricular remodeling — is the ventricle still dilated?
It is important to distinguish true myocardial recovery (true normalization of cardiac function after a reversible insult) from myocardial disease that is in remission. When there is remission, as in this case, myocardial dysfunction is still demonstrable (lack of inotropic or chronotropic reserve, elevated biomarkers, remodeling, abnormal ECG findings), and patients may still experience clinical events, including heart failure–related hospitalization and mortality. MRI imaging can also be helpful, in that persistent myocardial fibrosis strongly indicates a disease in remission. Nevertheless, in the case of true recovery (as evident from a completely normal ECG, echocardiogram, biomarkers, and so on), a trial of medication withdrawal with appropriate surveillance may be considered.
FOLLOW-UP: December 30, 2013
We discussed the various options with the patient. He ultimately chose option 2: Do not replace the battery; keep taking the heart failure medications. He reported feeling “100%,” going to the gym regularly, and working full time as a computer analyst — all without incident. He agreed to follow up in a year to have a repeat echocardiogram and laboratory testing.
On his return clinic visit, approximately 1 year from the discussion, his echocardiogram parameters were unchanged and his N-terminal pro-BNP level was within normal limits. He had not experienced any signs or symptoms of cardiac arrhythmia or heart failure and wanted to continue to stave off a battery upgrade. He said he didn’t mind continuing the medications, noting “If it isn’t broken, don’t try to fix it.”
14 Responses to “Doc, Do I Really Need a New Battery?”
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The improvement is extraordinary. First I review the original diagnosis and the new information to make sure everything is OK. You didn’t mention the variety of non ischemic cardiomyopathy. It is important to be sure the original diagnosis is not a transient cardiomyopathy for example a viral infections or takotsubo cardiomyopathy. Without history of cardiac arrest, VF, hemodynamically significant VT, history of familiar sudden death or unexplained syncope. If the patient have LVEF of 50% and no significant abnormal findings. The usefulness of the ICD is in question. I recommend do not replace the battery and keep taking the heart failure medication. I some cases I recommend to perform a CPX stress test.
It is interesting you note he “barely has any signs of heart failure.” that indicates there are some signs. So he needs the meds. As to the ICD, it seems that replacement provides more risk than benefit at this point. His insurer may even say that he no longer meets HRS criteria for a device so they won’t pay for it.
ICD efficacy in this patient should be viewed as a dynamic process and risk, specifically of VT/VF when his EF was 25% versus now which is markedly reduced if any at all. It is also unlikely that he has having asymptomatic ATP-terminating arrhythmias. Battery replacement is not necessary. Transient cardiomyopathy is plausible. Keep on medications as EF is low normal and a baseline cardiopulmonary before the decision about changing therapy.
Not to increase testing but If the decision is not clear on how to proceed an AdreView – MIBG scintigraphy, recently approved by the FDA, has a particular indication in cases like these to quantify cardiac sympathetic nervous system activity. An increased or normal myocardial uptake of MIBG, reflecting preserved neuronal and normal sympathetic activity correlates with improved survival and a very low risk of SCD.
Interesting case! Thanks for sharing.
This is a common situation. I think it depends on the likely aetiology. Many people with takotsubo / post ITU stay / a fairly rapid myocarditis / nutritional cardiomyopathy can improve and I give people the option of not having a replacement device. Some like the security of their device and some are glad not to have something done. I’m a little more circumspect if the aetiology is ischaemic as there is likely still scar there, or in some of the inherited cardiomyopathies, where ultimately progression is likely.
I’d vote for option 2 as well. anyone think different out there??
I choose (1).
As an implanter I’ve always taken the approach that if the reason for initial implant was correct, then proceeding with generator replacement is proper. We have all seen patients with fluctuating EFs, and who’s to know that 6 months from now the cardiac function hasn’t deteriorated again. Especially those patients who have idiopathic cardiomyopathy who may be “prone” to repeated episodes. I find it interesting that the initial implant was 8 years ago and just 3 yrs ago the EF was 25%, but has now normalized.
This is, indeed, a common scenario. The 2013 AUC for ICD rank this indication as ‘may be appropriate.’ This is clearly an example of a decision in which shared decision making with the patient is crucial.
Totally agree with the shared decision making. Have to take issue with the idea that you need to stick with the original decision on the ICD. The battery replacement is an opportunity to re-assess the decision with whatever new information is available – incorporating what has changed – which may include a changed perspective by the patient.
I would stop the spironolactone and see how he does, the prognosis is improved if he does not need a diuretic. I agree with reassessment of the ICD, and involve the patient in the decision including a decision for watchful waiting without battery change.
Everyone- thank you for these great comments. I completely agree with the concept of shared decision making but have been surprised by how seldom this occurs in a detailed manner when we recommend ICD implantation and/or battery replacement in the real world.
For a decision as complicated as preventible risk of sudden cardiac death, that likely varies with age, comorbidities, changing disease state etc. do most of us even understand the pros and cons for each patient enough to advise appropriately? Do we have enough data to do so?
With clinical decisions surrounding less complex disease states such as hypertension and dyslipidemia surrounded by lack of clarity, how do we best advise patients stricken by the syndrome of heart failure about decisions like ICD, LVAD, palliative care etc?
Of course,I will not recommend replacing battery, and keep observing patient,especially he never use I D while having low EF.I and many ,even think that low EF is not good predictor of arrhythmic death.
I think there is a relatively recent data on such group of patients, so that after an average of 6-8 years where they did not receive any shocks (primary prevention pts), this group of patients was randomized to battery exchange Vs no redo.
and as far as I remember about 30% of ICD pts had some shocks in the next3-4 years.
however this data should be analysed carefully, especially that some of those pts, may have some recovery of their LV function, either because of medication, PCI or CRT.
Also consideration should be given to other comorbidities, and patients preferences.
I don’t understand why “shared decision making” is such a common phrase. It seems like a politically correct phrase, which really answers little. The phrase suggests that physicians are often irrationally paternalistic and need to practice “patient centered” medicine ( a phrase even more demeaning).
We are decision framers. The decisions should obviously incorporate the patient’s values. We don’t ” share” in the actual decision making, as this implies that our values play a role. Rather we guide the patient. Human values are complex, dynamic, and multidimensional, including longevity and quality of life balances. As mentioned, the science of quantifying and maximizing such values is in its infancy.
OK….needed to say that. I usually slowly wean the heart failure medications off, following LV function and dimensions, as well as BNP levels. I am only comfortable with such an approach for adherent and medically reliable patients. I would likely start this months before the ICD battery is due. If all parameters remain near normal, not replacing the battery becomes even more reasonable.
The MIBG scintigraphy risk stratification idea is quite interesting , and more feasible than a cardiac MRI looking for LGE, as there is an ICD. I would like to learn more about that. For example, how do results vary with beta blocker use and LVEF in a given patient?
Thanks for the discussion.
Really good point – why should the decision be shared. It is the patient’s decision – with our assistance.