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100 Q in Cardiology

100 Q in Cardiology

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10/05/2015

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Roy M John

An implantable cardioverter defibrillator (ICD) serves as prophy-
laxis against sudden collapse and death from rapid ventricular
arrhythmias. In general, all ICDs sense the heart rate and provide
anti-tachycardia pacing or deliver synchronised (cardioversion) or
unsynchronised (defibrillation) shocks. Some of the modern ICDs
also incorporate dedicated pacing function; patients with heart
block or sinus node disease may be dependent on these devices just
like any patient with an implanted cardiac pacemaker.
Like pacemakers, ICDs have to be checked by telemetric
interrogation at periodic intervals to confirm integrity of the lead
systems and proper function of ICD components including
adequacy of battery voltage. Reprogramming of the various
parameters that govern pacing, arrhythmia detection and therapy
may be necessary from time to time. Such routine follow up,
usually undertaken at established arrhythmia centres, should
occur at 3 to 6 monthly intervals in the absence of major inter-
current events. Some issues specific to this group of patients can
be summarised as follows:

1. Avoid rapid heart rates

In its basic form, arrhythmia detection algorithms of ICDs rely on
a programmed heart rate threshold. Once this is exceeded for a
defined period of time, the device may deliver therapy
irrespective of whether the arrhythmia is of ventricular or supra-
ventricular origin. In a ventricular-based ICD, the shock energy
vector is designed primarily to encompass the ventricles.
Consequently, atrial arrhythmias may fail to convert such that
multiple inappropriate ICD shocks may result. Further, if anti-
tachycardia pacing is delivered in the ventricle for an atrial
arrhythmia, ventricular arrhythmias may be provoked creating a
pro-arrhythmic situation. The newer ICDs incorporate atrial
sensing to improve arrhythmia discrimination but it must be
remembered that any algorithm that improves specificity for
ventricular arrhythmia will entail some loss of sensitivity.
Cognisant of the above, it is imperative that atrial arrhythmias are
adequately treated in these patients, particularly the paroxysmal

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100 Questions in Cardiology

form of atrial fibrillation that is commonly associated with rapid
rates at its onset. Occasionally, RF ablation of the AV node is
necessary. Beta adrenergic blockers should be an integral part of
therapy in most ICD patients.

2. Recognise ICD—drug interactions

Antiarrhythmic drugs have the potential for interacting with an
ICD in several ways. Drugs such as flecainide and amiodarone
can increase pacing and defibrillation thresholds. In patients with
a low margin of safety for these parameters, use of these drugs
may result in failure of pacing or defibrillation. Secondly, these
drugs can slow the rate of ventricular tachycardia below the
programmed rate threshold for detection by the ICD; failure of
arrhythmia detection can result. Some rarer interactions include
alteration of the T wave voltage by drugs or hyperkalaemia
resulting in double counting and inappropriate shocks.

3. ICD wound management

As an implanted device, the system is susceptible to infections.
Pain and inflammation of the skin over the ICD may herald an
infective process. Similarly, unexplained fever, particularly
staphylococcal septicaemia may indicate endocarditis involving
the leads and/or tricuspid valve.

100 Questions in Cardiology

189

89 How do I follow up the patient with the
implantable cardioverter defibrillator?

Mark Squirrell

Follow up of the patient with an implantable cardioverter de-
fibrillator (ICD) demands an integrated team approach. The
cardiologist, technical staff and nurses involved should have a
wide experience and knowledge of pacemakers and general
cardiac electrophysiology. Current generation ICDs do not just
shock the heart but provide complex regimens of tachycardia dis-
crimination and anti-tachycardia pacing (ATP) as well as single
and dual chamber bradycardia therapy.
Routine follow up may occur in a tertiary centre or a local
hospital as long as the expert staff and necessary equipment such
as programmers and cardiac arrest kit are available. Follow up
should start before the device is implanted with an educational
programme and support for the patient and immediate family
members. Videos, information booklets and meeting other
patients with ICDs may be of benefit.
No consensus exists as to the interval between routine follow
ups. Previously the patient had to return every month or two to
have a capacitor reform. This is not now necessary, as all modern
ICDs will undertake this automatically. With most current
devices a 3 to 6 month interval is usual but treat each patient
according to their individual circumstances.
Good management of the ICD should aim to achieve the
following objectives:

11 Monitor the performance of the therapy delivered by the
device, look at the success and failure of the programmed
regimes and any acceleration of arrhythmias. Use this infor-
mation to optimise clinical effectiveness of the programming.
22 Measure necessary parameters of the ICD and leads to ensure
correct function. These should include lead impedance, shock coil
impedance (if possible non-invasively), battery voltage, charge
time, R and P wave amplitudes as well as pacing thresholds.
33 Review the intracardiac electrograms to ensure no inadvertent
sensing of noise or other interference.
44 Maximise device longevity by safe and effective reprogramming
of parameters.

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100 Questions in Cardiology

55 Minimise the risk of complications occurring both from in-
appropriate therapy delivered to the patient and those associated
with wound and pocket infection.1
66 Anticipate the elective replacement of the device and plan for
this eventuality.
77 Provide a support structure for the patient and their family
including advice, counselling and education. Some centres
provide a formal patient support group; there are both positive
and negative views on this practice.2,3

RReeffeerreenncceess
1 Troup P, Chapman P, Wetherbee J et al. Clinical features of AICD
system infections. Circulation 1988;7788:155.
2 Badger JM, Morris PLP. Observations of a support group for automatic
implantable cardioverter defibrillator recipients and their spouses.
Heart Lung1989;1188: 238–43.
3 Teplitz L, Egenes KJ, Brask L. Life after sudden death: the
development of a support group for automatic implantable
cardioverter defibrillator patients. J Cardiovasc Nurs 1990;44: 20–32.

100 Questions in Cardiology

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