Key result
Patient willingness for ICD generator exchange drops ~31% as hypothetical SCD risk decreases.
Why the study?
Less attention has been paid to ICD generator exchange decisions, despite potential changes over time in sudden cardiac death risk, procedural complication risk, quality of life, or prognosis.
How do patients make decisions regarding ICD generator exchanges when presented with varying risks of sudden cardiac death?
Cross-Sectional (n=50)
How do patients make decisions regarding ICD generator exchanges when presented with varying risks of sudden cardiac death?
Patients' willingness to undergo ICD generator exchange decreases as their risk of sudden cardiac death decreases, though therapeutic inertia and reliance on physician recommendations remain strong drivers of decision-making.
Supports risk-informed ICD counseling; leaves open effects of decision aids on exchange rates.
BACKGROUND: Shared decision-making is mandated for patients receiving primary prevention implantable cardioverter defibrillators (ICDs). Less attention has been paid to generator exchange decisions, although at the time of generator exchange, patients' risk of sudden cardiac death, risk of procedural complications, quality of life, or prognosis may have changed. This study was designed to explore how patients make ICD generator exchange decisions. METHODS: Emory Healthcare patients with primary prevention ICDs implanted from 2013 to 2021 were recruited to complete in-depth interviews exploring perspectives regarding generator exchanges. Interviews were conducted in 2021. Transcribed interviews were qualitatively coded using multilevel template analytic methods. To investigate benefit thresholds for pursuing generator exchanges, patients were presented standard-gamble type hypothetical scenarios where their ICD battery was depleted but their 5-year risk of sudden cardiac death at that time varied (10%, 5%, and 1%). RESULTS: Fifty patients were interviewed; 18 had a prior generator exchange, 16 had received ICD therapy, and 17 had improved left ventricular ejection fraction. As sudden cardiac death risk decreased from 10% to 5% to 1%, the number of participants willing to undergo a generator exchange decreased from 48 to 42 to 33, respectively. Responses suggest that doctor's recommendations are likely to substantially impact patients' decision-making. Other drivers of decision-making included past experiences with ICD therapy and device implantation, as well as risk aversion. Therapeutic inertia and misconceptions about ICD therapy were common and represent substantive barriers to effective shared decision-making in this context. CONCLUSIONS: Strong defaults may exist to continue therapy and exchange ICD generators. Updated risk stratification may facilitate shared decision-making and reduce generator exchanges in very low-risk patients, especially if these interventions are directed toward clinicians. Interventions targeting phenomena such as therapeutic inertia may be more impactful and warrant exploration in randomized trials.
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Montembeau et al. (2023) conducted a cross-sectional in Primary prevention implantable cardioverter defibrillators (ICDs) (n=50). Standard-gamble type hypothetical scenarios regarding ICD generator exchange was evaluated on Willingness to undergo a generator exchange at varying 5-year risks of sudden cardiac death. Patient willingness to undergo ICD generator exchange decreased from 48 to 42 to 33 (out of 50) as hypothetical 5-year risk of sudden cardiac death decreased from 10% to 5% to 1%.
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