An ICD is an implantable cardiac defibrillator. They are used for people who are high risk sudden cardiac death due to heart arrhythmias of ventricular tachycardia or ventricular fibrillation. They are often implanted as a preventative measure when the heart has a poor pumping ability as this makes one prone to arrhythmias. If the ejection fraction (pumping ability) is 30% or less and doesn’t show signs of improving your healthcare provider may consider implanting one.
Special care should be placed not to put excessive strain on the shoulder, arm and torso area where the ICD is implanted. Doing so may damage the ICD or the leads going from the unit to the patient’s heart. For this reason strength training with heavy repetitive weights is often discouraged. The exercises which would potentially damage the leads involves exercises with the arms overhead, such as a Military or shoulder press, seated fly’s,overhead triceps press. By heavy weights we are talking about weights upwards of 100 lbs or more with repeated repetitions and multiple sets. The wiring goes under the first rib, repeated bending and stress to the wires in this area can damage the leads. If your work involves this type of activity be sure to discuss this first with your cardiologist.
- Exercise with a friend or family member who is familiar with your condition and knows what to do in the event of an emergency.
- If you exercise at high intensities, you should make sure you have a specific guideline from your cardiologist about your heart rate range. If the heart rate is too high the ICD may sense it as Ventricular Tachycardia. Wearing a heart rate monitor can help you to watch your heart rate range and avoid exercises that spike the heart rate up into the threshold in which the defibrillator is programmed to respond. Your Cardiologist can adjust your ICD settings to recognize the difference between a normal increase in heart rate from exercise and that associated with an abnormal heart rate or rhythm. You should include a low-level 5 to 10 minute warm-up and cool-down phase for aerobic exercise (i.e., walking, cycling) to allow for a slow and steady increase in heart rate.
- The ICD can be affected by magnetic or electrical fields. You should avoid this and opt for something simpler such as the sum of skinfolds. Heart rate monitors are unlikely to cause any problems in the gym setting. Avoid Bio electric Impedance devices which are used to measure body fat.
Going against strong headwinds in his own community of heart specialists, Dr. Kramer emphasizes three important issues that come about when older patients with ICDs face battery depletion.
First, he asks heart doctors to re-evaluate whether the patient still benefits from the ICD. Perhaps, the original heart problem has improved?
Second, he points out that a patient’s experience living with the device may have changed their mind about keeping it active. Perhaps, a patient with inappropriate shocks no longer wants the device?
Third, since the original implant, a patient may have changed their goals of care. Many patients no longer desire life-sustaining shocks—for whatever reason. It’s their choice; but they aren’t often asked.
You may wonder why such obviousness isn’t the norm?
It’s because our healthcare system imparts significant barriers. Dr. Kramer nicely explains two important hurdles. One is that healthcare in the US is fragmented, especially for the infirmed and elderly. Patients may have many doctors, and care is often not well-coordinated. This means, an installer, a proceduralist like me, is left discussing end-of-life care with patients immediately before ICD surgery. That’s not good. I am married to a hospice doctor, so I sort of know how to manage these conversations. This is not the norm for procedure-oriented heart doctors. The other barrier to getting the elderly the best care is our system’s misguided incentives. In our current fee-for-service system, I am rewarded for doing, not discussing not doing. In fact, not doing stuff is very risky—both legally and professionally (ie. loss of referrals.)
Finally, Dr. Kramer and his colleagues call for heart doctors to take the lead in starting “the conversation” with ICD patients. He wants us to share the decision of using invasive, potentially dangerous or ineffective care with the patient. He also asks the scientific community to study the outcomes of patients who undergo elective ICD generator changes. These should not be controversial recommendations.
It’s a huge mistake to equate this kind of smart thinking to rationing. Aligning evidence-based care, especially potentially burdensome surgery in elderly patients, with the goals of the patient is not rationing. It’s moral, ethical and obvious.
There are issues with ICD that patients struggle with. These include the comfort of the ICD, the cosmetic appearance,the stress of having it fire, frequency of battery replacement, leads wearing out, and it working appropriately. I have included a few great resources to help you in living with an ICD.