It's a very common scenario: an older gentleman, Mr. M, is 7 years out from his large anterior wall myocardial infarction (heart attack) who has been doing fairly well as a car salesman, but notes exertional fatigue. He wonders why he might need an ICD, even this late after his heart attack:
I’ve been talked to about putting a device in my chest that is supposed to regulate the heart. I’ve talked to a few different doctors on it, and I thought I had a grasp on the situation. But my understanding of it is that at the present time it's not a necessary thing. I’m 6 years removed from having my original procedure; I want to know why it's important to do it now. Right now, for me, right at this particular moment, there's no reason for me to do it. That's why I’m having such a hard problem as far as making a decision on it.But the discussant does a good job explaining the rationale for recommending a defibrillator, even this late after a heart attack:
Mr M is beyond the early post-MI phase, but is well-represented by 2 of the previously cited trials. The control groups of the MUSTT and MADIT 2 trials enrolled patients an average of 3 and 7 years following MI, respectively. These trials included patients with a high incidence of CHF and a modest rate of -blocker and ACEI use and found that during a mean follow-up of 3 years, mortality rates were more than twice those documented in VALIANT. A substudy from MADIT 2 evaluated the influence of time post-MI on benefit derived from ICD implantation. In this analysis the reduction in mortality associated with ICD implantation persisted even in patients enrolled longer than 10 years following an MI. Therefore, current practice is to wait at least 6 weeks post-MI but not to limit how long after MI an ICD will be considered. In summary, Mr M can assume he continues to be at elevated risk for arrhythmia despite the 7 years that have passed since his MI, and that an ICD could reduce that risk.I hear this resistance to implanting patients with ICD's late after myocardial infarction often. But our reluctance to advise patients about these devices might just cost someone their life.
This article does a great job reviewing the pro's and con's of defibrillator implantation and their benefits late after a prior heart attack. Unfortunately, it requires a prescription to view the entire text of the article, but I encourage doctors to review this piece if they care for patients that might be eligible candidates for this technology.