Implantable Defibrillators Should NOT Be Installed Right After Cardiac Failure |

Well, Dick Cheney had one. My step-niece had one. But, were they necessary?

What am I talking about- an implanted heart (cardioverter) defibrillator (IVD). These devices are supposed to “shock” the heart into a normal rhythm pattern, when the device detects an irregular heartbeat (in these patients who have experienced heart failure). These implantations are very expensive and employ a fair amount of hospital resources.

The IVD’s are not supposed to be installed on patients who have recently experienced a heart attack or underwent bypass surgery. One is supposed to wait (three to four months) to insure that there is a hope for life expectancy, before such major invasive surgery. Those are the experiential guideline- but it seems that they are violated some 22% of the time.

Dr. Sana Al-Khatib (lead author) et. al. reported these new results in JAMA. The researchers examined the national registry data for those who had the device installed from CY 2006 through 2009 (111,707 subjects). Of the 22,145 that received the IVD against recommendations, the death rate was 3 times the rate for those that met the criteria (0.57 v. 0.18%). In addition, there was no discernable decrease (or increase) in the (non-evidence based) IVD Â implantations over the four-year period of study.

What’s more annoying is that this is not really “news”. An international study, under lead researcher Dr. Hohnloser, reported in the NEJM similar conclusions (with a smaller cohort) in 2004. Of the 332 subjects they studied, the research indicated that the prophylactic use of IVD did not reduce mortality in high risk patients . They found that any reduction in mortality due to arrhythmia was offset by increased rates of death from other causes.

It turns out the real reason for the number (and increased rate of implantations) of IVD implantations was that CMS (Centers for Medicare and Medicaid Services) changed the guidelines by which physicians would be reimbursed for their installation in 2004.Â As is shown in the graph (NEJM link), implantation had been expected to skyrocket from 2004 to the end of the decade (which it did). Those CMS guidelines did not mimic the experiential data. One can hope that the health reform we continually hear mentioned will curb these excesses.