ICD deactivation Patient Journey Julia decourcey Consultant Nurse Kings College Hospital 05.05.10
Internal Cardiac Defibrillator Used in pts at high risk of sudden cardiac death ie EF > 30% Previous survivor of cardiac arrest. NYHA I, II or III, Wide QRS ICD therapy reduced all cause mortality by 23% compared to placebo No effect on morbidity Shorter hospital stays MADIT II SCD- HeFT COMPANION
Who gets an ICD Survived VT or VF VT with syncope Previous MI Ischaemic primary prevention LV Non compaction familial - high risk of sudden death including long QT syndrome, HOCM,. Brugada syndrome arrhythmogenic right ventricular dysplasia (ARVD), Surgical repair of congenital heart disease.
When conservative management fails era of device therapy for treating refractory patients Nice Excludes non ischaemic patients / ignores US (AHA) & European Guidelines where most CRT implants include ICD Over next decades, pacing devices will become more sophisticated and be a key part of CHF therapy but as an adjunct to drug and lifestyle therapy
Optimization of therapy: guidelines A B lipids-statins CAD - life style HTN - 130/80 DM - tight control exercise beta blocker ACE Inhibitor ARB hydralazine + nitrate ICD sodium Diuretics/ educ anti-aldosterone digoxin D/C bad drugs CRT / ICD Bi Ventricular PPM structural surgery LVAD transplantation Inotropes C CAGG / PCI MV surgery End of life care Hospice D
Mode of Death in Patients with Heart Failure Pump failure with progressively reduced cardiac output and reduced organ perfusion often with runs of poorly tolerated VT Sudden death MI Arrhythmia
Case 1 MC 72 yr old lady - Enjoyed frequent overseas holidays with husband L & R ventricular dysfunction diagnosed in 2003 post an admission with a tachycardia Echo - EF < 25% + reduced RV function Very symptomatic with fatigue and feelings of panic DCCV to SR. Unwell after 5 days - Amiodarone with DCCV to maintain SR. 1992 MVR with Mechanical valve Osteoporosis
Cont. HF Community nurse support since 2004. Few admissions to Lewisham for IV Frusemide - PC support 2004 Referred to Kings College Hospital. NYHA III. Good HF drug therapy. (Candesartan, Carvedilol, Bumetanide) and Amiodarone, Simvastatin, Paracetamol, Levothyroxine, Aldendronate, Warfarin. Simvastatin stopped, Spironolactone added improved to NYHA class IIb Kings OPD clinic. DGH documented episode of VT / dizzy spells / persistent increased fatigue. No fluid overload on low dose diuretics. BI Ventricular Pacemaker with ICD 26.04.05 Improved. PC withdrew home support and now enjoying holidays over seas
MC cont HF nurse noted deterioration, fluid overloading. Pacing notes suggest all fine. husband asked HF Nurse for R/V No ICD therapy but HR. Beta blocker increased and Bi V optimisation - improved slightly again. 2008 - PC / CHF team. Recurrent episodes of fluid over load BP low drugs reduced. PPC discussed - ICD deactivated, DNR, No further pacing f/u Ongoing deterioration / fluid over load over few months Seen in Kings as husband s had OPD in Cardiac. BP low but HR high. Beta blocker increased.
MC con Not well. Pacing check - No Bi V pacing - battery flat. Long discussion in view of PPC MDT - listed for new BI V pacing box 13.03.09 Sept 15.09.09. PC and HF support at home. Good HF drugs. Fentanyl patches for oesteoporois, Oromorph at night, Pro plus and fortisip, home oxygen. Nov 2009 symptomatic but stable no oedema Died in 2010 - all care preferences met
I think I am one of the lucky ones and happen to have met an incredible bunch of staff I know what I do and no not want as I have had so much time to discuss it with various staff and family Tell him not to come see me in case as he might make my heart race as that makes me really ill I love my nurses at home and the same ones see me
Case 2 Mr DF 58 yr old man. NOK wife LVEF 18%, RV function reduced ( 22.08.08) CABG in 2000. MI X 3 AAA Repair in 2006 Popliteal Aneurysm repair 2007 COPD Type II Diabetic Depression HF therapies ( Eplenerone, Bumetanide Enalapril, Carvedilol) + Diazepam, Citalopram
Case 2 Mr DF Referred to his local DGH HF by CHFN but admitted to local hospital in the interim Tx with Iv frusemide and Metolazone Referred directly from DGH to Kings for pacing Bi Ventricular Pacemaker / ICD on 7.11.08 Minimal improvement. Seen in End stage heart failure clinic Plan of care symptom control / end of life care PPC - ICD off, no further admissions to hospital. ICD deactivated on 27.01.09 Hope they are not going to talk me out of turning off ICD
Case 2 Mr DF Community matron and PC nurse in support at home HF drugs stopped Fluid overloaded but resisted admission to hospital tried metalozone but little effect IV frusemide for few days with some effect Home with Oxygen Panic feeling at night / wife distressed. GP at night - nil to offer as not for active tx and to call ambulance. Declined hospital as per PPC. Settled with oxygen Died at home later on 15.02.09
I did not know what to do I was afraid of him as he was shouting in the night and too strong for me I should not be on my own, could not do this on my own Did not know who to call in the night Not enough support at home - powerless to provide good help No one to call when they feel there is an emergency situation We were worried about his panic feeling and racing heart beat
He drove us potty Worried we might overdose or under dose Every one in family was much more relaxed Did not include dad in decision to the end asked family what they thought Very hard at home and heart breaking Did not get to eat until 11 pm some days The responsibility was too much Get me home it is your job and you told me that you will always consider my wishes Bowel days were exhausting
We just about coped with the caring and there was 4 of us looking after him full time We would not had it any other way despite how difficult it was
ATP ICD deactivation / discussion points Drugs (when / if to stop drug therapy) Misconceptions Pt Information re ICD at each clinic or ICD check Communication ( family / pt / home care / ambulance crew / Primary care / PC hospice / implant centre / Mortician) Consent / record of discussion / transfer of information Magnets
Discussion re ICD care ICD shocks at terminal stages / sequence of ICD shocks for terminal arrhythmias Consequences if ICD not deactivated
Preparation of patients for Bi V PPM & ICD therapy Not all pts benefit CRT / Bi V PPM is not a cure, it is an adjunct to care pts continue to have high mortality rate and supportive / palliative care should continue ICD alone does not improve symptoms ICD - major psychological trauma ICD inappropriate shock therapy ICD therapy / conflict with good end of life care
ATP via ICD
ICD shock for VF termination