Managing And Following Patients

In the United States, patient registration and tracking is mandated United States government. Once registered, a patient receives a permanent identification card to carry with them at all times. A Medic Alert is strongly encouraged and provided by some manufacturers. Patients should be followed initially every 3 mo for at least 6 mo and then at 6-mo intervals. They should be advised they are likely to receive therapies. At the follow-up visitation, a history of symptoms that might suggest tachyarrhythmias should be obtained. The diagnostic and episode data should be reviewed. Current data also include stored episode electrograms to allow review of NSVT as well as delivered therapies for sustained arrhythmias. Device sensing, pacing thresholds, and lead impedances should be obtained.

In general, ICD pulse generators have 3-6-yr longevity depending on usage. The programmer allows evaluation of battery status. As the device approaches the elective replacement interval (ERI), follow-up visits should be intensified. In general, once the device reaches ERI, it will operate normally for at least 3 mo, depending upon frequency of therapy. Capacitor deformation occurs during periods when no shocks are delivered, and will result in longer charge times as well as decreased battery longevity. Current ICDs perform an automatic capacitor re-formation that charges the capacitors and delivers the energy to an internal test load. This function improves subsequent charge times and battery longevity. Capacitor re-formations should be conducted manually every 3-6 mo if they are not automatically conducted.

Typically, 40% of patients receive a therapy within the first year after implant, and 10% per yr thereafter. Fig. 4 shows the percentage of patients without ICD shock therapy over time. After a patient experiences a first therapy, they should seek medical attention for assessment of the appropriateness of the therapy. If multiple ICD discharges are experienced, medical attention should be immediately sought. Failure to discriminate between ventricular and supraventricular arrhythmias is the most common reason for inappropriate shocks. Indeed, up to 40% of shocks are delivered inappropriately for supraventricular rhythms. Irregular V-V intervals with a variability greater than 30 ms suggest a SVT such as AF. Rate stability is a commonly used enhancement to improve the appropriateness of device therapy observed in AF with a rapid ventricular response.

Therapy that is conducted during physical exertion and is noted to have gradually increasing V-V intervals, failure of device therapy, and gradual decreasing V-V intervals

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