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  1. Conelius, Jaclyn PhD, FNP-BC, CCDS, FHRS

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Q: Question: My patient has an implantable cardioverter defibrillator, which is causing him a great deal of pain and anxiety. He is afraid to drive his car and rarely leaves his home. How can I help him adjust to this device?


An implantable cardioverter defibrillator (ICD) is the treatment for cardiac patients who meet the criteria set by the Heart Rhythm Society. They can receive an ICD for primary or secondary prevention. The ICD is placed to prevent sudden cardiac death (SCD) in patients who are at risk of or have had SCD, ventricular fibrillation, or prolonged ventricular tachycardia (VT). The shocks delivered by the device can cause pain and anxiety; however, when programmed appropriately, unnecessary shocks can be avoided. As you described, the pain patients experience from the device is not only physical but mental as well. The literature describes quality-of-life issues in patients with ICDs such as not wanting to work, avoiding financial responsibilities, decreased physical activity, avoidance of driving, fear of the device failure, and sleeping difficulties (Tagney et al., 2003).


It is helpful for you to know that about 10% of delivered shocks are inappropriate (i.e., a shock for atrial fibrillation instead of ventricular fibrillation) and can lead to pain, unnecessary trips to the emergency room, hospital admissions, and a negative impact on quality of life (Auricchio et al., 2015). Clinical trials to evaluate ways of programming ICDs in order to reduce the number of inappropriate shocks have been conducted. The results suggest that increasing antitachycardia pacing (ATP) to break the VT before a shock can be delivered reduces the overall number of shocks and the accompanying pain. This ATP can be programmed in all devices no matter the manufacturer (Auricchio et al.; Wathen et al., 2001; Wathen et al., 2003; Wilkoff et al., 2006). The following brief case study illustrates how home care clinicians can be instrumental in bringing this to the attention of the cardiologist and facilitating improved outcomes for the patient.


Recently, a 79-year-old male presented with a history of VT treated with an ICD. His home care physical therapist had phoned the office to report the patient's device was shocking him at least two times daily and the patient stated "I can't take it anymore." The patient admitted to a great deal of anxiety with regard to not knowing when he would feel a shock again and was not leaving his home as a result. He was also reluctant to participate in his home physical therapy program for fear this activity would trigger an arrhythmia and a shock from his ICD. He was placed on amiodarone for his VT but then continued to have refractory VT for which he received shocks. A VT ablation was performed by the electrophysiologist, which improved his VT for only a couple of months.


After about 4 months he began to complain of dizziness, weakness, and tremors. His device was interrogated and it was found that he began to have slow VT at a rate of about 130 beats per minute, as well as some faster VT in which he received some shocks. His device was programmed to provide more ATP during the VT episodes. He returned to the office 2 weeks later for check of his ICD and stated that he had not felt any shocks from his device. Once the device was interrogated it was found that all of his VT was terminated by the painless ATP therapy. Although his simple programming change did not cure his VT, it did improve patient outcome by decreasing the amount of unnecessary shocks through the ICD.


Implications for Clinicians

Although physical pain from a shock depends on the patient's threshold for pain and is different among patients, it is often described as "a horse kicking you in the chest." It is important that home healthcare clinicians investigate whether and how often the patient is receiving shocks and how they are reacting to the shocks. Patients don't always reveal the psychological aspects of receiving shocks to their cardiologist. Home care clinicians should be alert to signs of depression, anxiety, fear of performing activities of daily living, and fear of leaving their home or driving. This information should be communicated to the cardiologist responsible for the ICD. Finally, keep in mind that sometimes a simple programming change can reduce or even prevent the painful shocks that can cause such quality-of-life issues for patients.


AHRQ Study: Affordable Care Act Could Narrow Racial, Ethnic Disparities

The Affordable Care Act could potentially improve coverage, access, and healthcare use for all racial and ethnic groups and also narrow racial and ethnic disparities in those areas, according to an American Journal of Public Health article by AHRQ researchers. Authors used pre-Affordable Care Act data from AHRQ's Medical Expenditure Panel Survey to examine disparities among adults targeted by coverage expansions. They found targeted groups had lower rates of coverage, access to care and preventive services use, and some racial and ethnic disparities were widest within these targeted groups.

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Auricchio A., Schloss E. J., Kurita T., Meijer A., Gerritse B., Zweibel S., ...PainFree SST Investigators.(2015). Low inappropriate shock rates in patients with single- and dual/triple-chamber implantable cardioverter-defibrillators using a novel suite of detection algorithms: PainFree SST trial primary results. Heart Rhythm, 12(5), 926-936. [Context Link]


Tagney J., James J. E., Albarran J. W. (2003). Exploring the patient's experiences of learning to live with an implantable cardioverter defibrillator (ICD) from one UK centre: A qualitative study. European Journal of Cardiovascular Nursing, 2(3), 195-203. [Context Link]


Wathen M. S., Khaligi K., Voloson K. J., Rubenstein D., Lin A., Otterness M. F., DeGroot P., Stark A. J. (2003). Anti-tachycardia pacing of fast ventricular tachycardia improves quality of life in implantable cardiac defibrillator patients. Circulation, 108, IV-615. [Context Link]


Wathen M. S., Sweeney M. O., DeGroot P. J., Stark A. J., Koehler J. L., Chisner M. B., ...PainFREE Investigators. (2001). Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease. Circulation, 104(7), 796-801. [Context Link]


Wilkoff B. L., Ousdigian K. T., Sterns L. D., Wang Z. J., Wilson R. D., Morgan J. M.EMPIRIC Trial Investigators. (2006). A comparison of empiric to physician-tailored programming of implantable cardioverter-defibrillators: Results from the prospective randomized multicenter EMPIRIC trial. Journal of the American College of Cardiology, 48(2), 330-339. [Context Link]