ICD 23 Months/No shocking yet

[Concernedspouse]

Once an ICD always an ICD???

My husband had a mild M.I. and cath w/ two DE stents to the LAD Dec. 2004 at age 55. His father had died at 39 after what he thought was two weeks of arm pain from lifting his father's casket, but apparently it was a M.I. as he died in his doctor's office when he developed chest pain the day he died. My husband's resting heart rate pre-M.I. was betw 60-65 bpm. After the cath, he went home on Plavix, aspirin, Toprol, and cozaar. He'd already been taking Lipitor for a decade, oh and they added Zetia. He took the Plavix for 365 days at his doc's suggestion. A few weeks prior to the one year mark, we called to reconfirm the Plavix cessation at 1 year. He stopped taking the Plavix, waited seven days and then got his teeth cleaned for the first time all year. 16 hours later he awakened to a funny feeling and I raced him to ER. He went into v-tach and v-fib and sudden cardiac arrest within 10 minutes of getting to the Er. His heart was defibrillated back and he was transported to the heart center from our local small community hospital and went into the cath lab again. Doctor found one of the two DE stents had collapsed on one end, and he found a small clot. Put in a third stent and shored up the other. Was sending him home the next day but wanted a 64 slice CT first to check things out. Well, that started the dominos to fall. They discovered in this four color glossy photo image that there was some LVH. His ejection fraction was 80% though, and the LVH was there and revealed on echo the year before and nobody noticed/mentioned any issue. We told the doctors that his mom and sister both have it too without incident/issue/complication. Well, after keeping us on ice for several days while the EP returned from Christmas vacation and we rotten in the hospital, the decision was made to put in an ICD. We felt it was reasonable to be his 'paramedic onboard' so to speak. NO EP study was done. Just a team of interventionalists met and decided that he needed this ICD. So, we're now on month 23 without incident. No shocking needed so the thing hasn't fired. It has, however, paced him constantly...last interrogation shows 72% of the time it's ramping UP his heart rate. I hate Toprol and believe it's the culprit. He was on 100 mg and they finally let him reduce that by half to 50 mg and added amlodipine, and the pacing went from 64% to 72% and they had switched him to hyzaar. His BP at home is normal. At the doctor's office it spikes to 140/90. What's up with that? Adding insult to injury, we learned Oct. 15 about Medtronic's removal of the Sprint Fidelis lead off the market, and yes, his leads are those. So, on the 30th we went in and the Medtronic rep reprogrammed the sensor alarm to beep sooner rather than later if there is a malfunction or lead integrity issue. Lovely. Now we have the elephant in the room. There has no been an arrythmia requiring shocking in 23 months that the device has been in...the apothecary he's on isn't working well enough in the doc's estimation at keeping the blood pressure low enough, but the damn drugs make his heart rate so low that the pacemaker has to work constantly. Now what do we do? Wait for the lead to fracture or the battery of the device to wane and die. Then we'll be faced w/ what to do in probably four years time. Is it reasonable to not replace the device with an ICD but just use a pacemaker? Is it reasonable to remove the device, cap the wires, and be done with it in four years providing he hasn't had an arrythmia in that time? That would mean six years without an issue. Could we tweak the medications down and start over? He quit smoking when they put him in that first ambulance in 2004. The Toprol has made him gain weight, along with the quitting smoking, but he started exercising (treadmill and exercise bike) after cardiac rehab training and has no luck shaking off weight. Tried 1200 calories a day, good calories only, and 5 days a week 1 hr walking and biking minimum and lost 6 pounds after a 5 week diet. He's 6'3 and weighed 196-200 when the first M.I. issue happened. He's never had a weight problem. He sleeps at the drop of a hat now. He feels side effects, top to bottom on the list. We have an apothecary going into him and for what? Yes, Plavix for anti-platelets so those stents don't reocclude. Aspirin too. I suppose the Lipitor and Zetia are pertinent, but I believe fish oil and oat bran could work just as well, and did get his ratio better and cholesterol down 100 points 20 years ago when we started on this journey to fight his genes. How realistic is it to just remove the ICD and cap off the potentially faulty leads and use medication to ward off v-tach/v-fib instead of the device? The risk of perforation outweighs the risk of fractured leads right now, right? Shouldn't he start over with all this medication? I feel like he's WAY OVERMEDICATED and it's not working for the BP in their eyes, so why take it all? Nobody believes us when we tell them that his BP is normal at home. What do I need to do videotape the process here? Probably. I am ticked off. The cardiologist who did the second cath never believed my husband needed the ICD but didn't tell us that. The group mentality was that his father had had SCA and once they NOTICED the LVH they decided that was enough evidence to warrent the ICD. But, no tests were done while we rotted over the holiday time, and by the time they told us that was the decision, we were like, just do it and get us the hell out of here so we can go home...Have you ever had a patient who had his device removed under similar circumstances? If the device never fires, it is reasonable to not replace it when the current device's battery dies? Have the Medtronic leads fractured that are there for pacing function, or just defribrillating?

[Concernedspouse]

Fish Oil not recommended in those who have had M.I.? What study citation could you share to support that claim?

[Concernedspouse]

So reducing the beats per minute threshold setting on the pacemaker part down from 60 bpm to 50 bpm might be a better way to extend the battery life and let the heart do its own work, or am I missing something? I believe the clincher for putting in the ICD was that his father had what the convened doctors decided was sudden cardiac arrest. See, nobody asked us they were in an interventional cardiologist's pow-wow deciding whether to put this device in or not. They knew his father had died in 1961 in a doctor's office at age 39. Well, what they didn't listen to was the preface story: That his own father had died two weeks prior and he and his brothers carried the casket and my husband's father thought his arms were uniformly sore due to lifting the casket. So, my husband's father probably had a blockage brewing for two weeks prior to his death that took place in a doctor's office on the day he died, which was the day he first had chest pain. We've been second guessing the device the whole time.

[Michael J. McWilliams, M.D.]

good point Joe.  I have a patient that recently had a shock after 30 days (appropriate shock) and have seen others go longer than 5 years before their first shocks.

[joe h]

i had my icd for 3.5yrs, before it had to do any therapy or pacing.

[Michael J. McWilliams, M.D.]

What's up with that?

White coat hypertensions -- he gets nervous at the doctor.

Is it reasonable to not replace the device with an ICD but just use a pacemaker?

There are 2 things to reduce ventricular pacing.
1. extend the interval from the atrium to the ventricle to allow native conduction
2. decrease the rate at which it paces and let the heart do the work itself.

I am not sure that I understand the indication for the ICD  but it is not my role to second guess that.  The doctors saw an indication at that time.  This can be difficult sometimes.  In general, if you have the device, I would replace the generator when the battery dies.

I believe fish oil and oat bran could work just as well, and did get his ratio better and cholesterol and triglycerides down 100 points 20 years ago when we started on this journey to fight his genes.

You do not have data to make those assertions, in fact I think the data suggests there is good reason for statins.  Out bran is good too.  Fish oil is not recommended for people that have previous heart attacks and has been shown to increase ventricular arrhythmias in that setting.

Let your doctors do what they are trained for as far reducing the risk of future coronary events.

How realistic is it to just remove the ICD and cap off the potentially faulty leads and use medication to ward off v-tach/v-fib instead of the device?

I don't feel like I have the data to make that assessment.  If they  put in the defibrillator, that must have felt that it was indicated.  It is interesting question but I think you have to ask your doctor that one.

The risk of perforation outweighs the risk of fractured leads right now, right?

Absolutely!

Shouldn't he start over with all this medication?

Coronary disease patients should be on an aspirin, statin, plavix if DES, beta blocker and ace inhibitor.

Have you ever had a patient who had his device removed under similar circumstances?

No.

If the device never fires, it is reasonable to not replace it when the current device's battery dies?

That is my current practice.  I have one patient that I am likely not going to replace her pacemaker because the battery has lasted 20 years -- she is clearly not using it.  An ICD is a different story.  You may only need it once.

Have the Medtronic leads fractured that are there for pacing function, or just defribrillating?

90% of the time it is the pace sense componenet, 10% it is the defibrillator component.

I hope this answers most of your questions.  Whether or not to replace the device -- I think you need to talk to your EP about that one.

Thanks for posting.