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Heart Failure: Should I Get an Implantable Cardioverter-Defibrillator (ICD)?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Heart Failure: Should I Get an Implantable Cardioverter-Defibrillator (ICD)?
Get the facts
- Get an ICD.
- Don't get an ICD.
An ICD is often placed in people who have survived an abnormal heart rhythm that could cause sudden death. This decision aid focuses on whether to get an ICD if you have not had a heart rhythm that could be deadly but are at risk for one.
Key points to remember
- Your doctor may suggest an ICD if you are at risk of having an abnormal heart rhythm that could cause sudden death. Tests can show if you are at risk.
- Many medical facts play a role in whether you should get an ICD. For example, the amount of blood your heart pumps (ejection fraction) helps your doctor decide if an ICD is right for you. Your doctor also will consider other health problems you may have.
- The shock from an ICD hurts briefly. It's been described as feeling like a punch in the chest. But the shock is a sign that the ICD is doing its job to keep your heart beating. The ICD also can use painless electrical pulses to fix a heart rate that is too fast or too slow.
- Your doctor may also advise you to take medicine to reduce your chance of having a deadly abnormal heart rhythm. Also, some abnormal heart rhythms may be fixed with a procedure called catheter ablation. It destroys some of the heart tissue where the abnormal rhythm starts.
When you have heart failure, the lower chambers of your heart (the ventricles) aren't able to pump as much oxygen-rich blood as the body needs. Some people who have heart failure also may have abnormal heart rhythms that can cause sudden death.
The heart may beat so fast that the ventricles don't have time to fill with blood. This type of abnormal rhythm is called ventricular tachycardia (say "ven-TRICK-yuh-ler tack-ih-KAR-dee-uh"). Sometimes the heart quivers, or flutters, and stops pumping blood. This is called ventricular fibrillation (say "ven-TRICK-yuh-ler fib-ruh-LAY-shun"). If these abnormal rhythms are not fixed right away, the person may die.
An implantable cardioverter-defibrillator (ICD) is a battery-powered device that can fix an abnormal heart rhythm and prevent sudden death. The ICD is placed inside the chest. It's attached to one or two wires (called leads) that go into the heart through a vein.
An ICD is always checking your heart rate and rhythm. If the ICD detects a life-threatening rapid heart rhythm, it tries to slow the rhythm to get it back to normal. If the dangerous rhythm does not stop, the ICD sends an electric shock to the heart to restore a normal rhythm. The device then goes back to its watchful mode.
An ICD also can fix a heart rate that is too fast or too slow without using a shock. It can send out electrical pulses to speed up a heart rate that is too slow. Or it can slow down a fast heart rate by matching the pace and bringing the heart rate back to normal.
Before putting the ICD in your chest, your doctor will program it to send electrical pulses or a shock when needed. Whether you get pulses or a shock depends on the type of problem that you have and how the doctor programs the ICD to respond to it.
In some people who have heart failure, the ventricles don't beat at the same time. If these people also have a risk for abnormal heart rhythms, they may get a device that combines an ICD and a biventricular (say "by-ven-TRICK-yuh-ler") pacemaker. This pacemaker is also called cardiac resynchronization therapy (CRT). This type of pacemaker uses electrical pulses to make the ventricles pump at the same time. The ICD part of the device can give a shock to fix an abnormal heart rhythm.
Your doctor will put the ICD in your chest during minor surgery. You will not have open-chest surgery. You probably will have local anesthesia. This means that you will be awake but feel no pain. You also will likely have medicine to make you feel relaxed and sleepy.
Your doctor makes a small cut (incision) in your upper chest. He or she puts one or two leads (wires) in a vein and threads them to the heart. Then your doctor connects the leads to the ICD. Your doctor programs the ICD and then puts it in your chest and closes the incision.
In some cases, the doctor may be able to put the ICD in another place in the chest so that you don't have a scar on your upper chest. This would allow you to wear clothing with a lower neckline and still keep the scar covered.
Most people spend the night in the hospital, just to make sure that the device is working and that there are no problems from the surgery.
You may be able to see a little bump under the skin where the ICD is placed.
The shock from an ICD hurts briefly. It's been described as feeling like a punch in the chest. But the shock is a sign that the ICD is doing its job to keep your heart beating. You won't feel any pain if the ICD uses electrical pulses to fix a heart rate that is too fast or too slow.
There's no way to know how often a shock might occur. It might never happen.
It's possible that the ICD could shock your heart when it shouldn't. If that were to happen, you would have pain. The shock could make you fall out of bed, and that could injure you. You also might be afraid or worried about when the ICD might shock you again.
In rare cases, the shock could cause ventricular fibrillation. If this happened, the ICD would shock your heart again to stop the abnormal rhythm.
Many people say that they have a good quality of life with an ICD. But shocks—and the fear of shocks—can make some people worry too much. They may be afraid all the time that the ICD might shock them. This worry can reduce a person's quality of life.
An ICD often is placed in people with heart failure who have survived a dangerous abnormal rhythm. The ICD would protect them if they get another abnormal heart rhythm.
But it also may be offered to people with heart failure who haven't had an abnormal heart rhythm but are at risk for one.
You will have tests to see whether you are at risk for abnormal heart rhythms. These may include an electrocardiogram (EKG, ECG), an echocardiogram, or an electrophysiology study.
Your doctor will use these test results and your medical history to figure out if an ICD could help you. Your doctor also will rely on guidelines that help find out who might benefit from an ICD.1, 2 These guidelines will likely change often, because experts are doing new research and creating new technology. You and your doctor can work together to decide whether you want to get an ICD.
Many medical facts play a role in whether you should get an ICD. Your doctor will look at whether:
- You're taking medicine to treat heart failure and to prevent abnormal heart rhythms.
- You're expected to live more than 1 year.
- Your ejection fraction is lower than normal.
- You have passed out from previous abnormal heart rhythms.
- You have had a heart attack.
- You have class II or III heart failure. This means that you have some trouble doing everyday activities because of your heart failure symptoms.
Sometimes an ICD is not recommended.2 You and your doctor may decide against an ICD if any of the following apply to you:
- You're expected to live less than 1 year.
- You have frequent abnormal heart rhythms (ventricular tachycardia) that can't be controlled with medicines. An ICD would shock you repeatedly.
- You have class IV heart failure and heart transplant surgery is not an option. People who have class IV heart failure can't do any physical activity without symptoms. An ICD probably wouldn't help you live longer.
- You have an abnormal heart rhythm that can be fixed with catheter ablation. This is a procedure that destroys some heart tissue where the abnormal rhythm starts.
An ICD can prevent sudden death from an abnormal heart rhythm. ICDs may also help people who have heart failure live longer. This benefit has been shown in people older than 65 years.3
- ICDs can help lower the risk of dying suddenly from a heart problem. In studies, ICDs lowered the number of people who died because of a heart problem from about 16 out of 100 people to about 7 out of 100 people.4
- ICDs might also help lower the risk of death from causes other than sudden cardiac death. In studies, ICDs lowered the number of people who died from any reason from about 30 out of 100 to about 20 out of 100.4
- An ICD combined with a pacemaker (cardiac resynchronization therapy, or CRT) can also help people live longer and stay out of the hospital.5
There are several risks to getting an ICD. But the risks are different for each person. The risk for problems associated with the implant procedure might be higher for people who are 80 years or older.
During the procedure. If problems happen during the procedure, doctors likely can fix them right away.
- Serious bleeding could occur after placement of the ICD. This happens from 1 to 6 times out of 100. Serious bleeding doesn't happen 94 to 99 times out of 100.4, 6
- A lung could collapse (pneumothorax) from a buildup of air in the space between the lung and the chest wall. But a pneumothorax can be treated and people recover well. This happens less than 1 time out of 100. This doesn't happen 99 times out of 100.6
After the procedure. Problems after the procedure can be minor, like mild pain, or serious, like an infection. But your doctor can solve most of these problems. And most people do not have long-term problems.
- Pain, bleeding, or bruising soon after the procedure.
- The leads that attach to the heart may break or stop working right. This can happen between 2 and 15 times out of 100 after 5 years of having the ICD. So it does not happen about 85 to 98 times out of 100.4, 7 But the risk of a lead breaking or not working right appears to increase over time. One long-term study found that, after 10 years, 20 out of 100 leads had problems. This also means that 80 out of 100 leads didn't have problems.8 If a lead does break or does not work anymore, you would need surgery. The surgery would be more complex than that needed to replace an ICD battery.
- You could get an infection where the ICD is placed. This happens about 1 to 2 times out of 100. So there is no infection about 98 to 99 times out of 100.9
- The ICD could shock the heart when it shouldn't. There is no way to know if or when this could happen. It might never happen.
- There also is a chance that a manufacturer may recall an ICD for a problem. If this were to happen, you might need surgery to take out the ICD and leads.
Daily precautions. Some activities and situations can interrupt the signals sent by the ICD to the heart. You may need to adapt some of your activities. If you have an ICD, follow your doctor's specific instructions about care and precautions.
You will need regular monitoring and checkups with your doctor to make sure that the ICD is working.
It's important to keep taking your medicines for heart failure. You'll also need to follow a healthy lifestyle to treat heart failure. This may include watching how much fluid you drink, eating healthy foods that are low in salt, and not smoking.
If the ICD gives you a lot of shocks, your doctor may prescribe the rhythm-control medicine amiodarone. This medicine helps prevent abnormal heart rhythms and may keep the ICD from sending shocks too often. Your doctor also could suggest catheter ablation to lower the number of times the ICD shocks you. Catheter ablation can lower the chance of some abnormal heart rhythms, such as atrial fibrillation or ventricular tachycardia. These rhythms can cause the ICD to shock you.
ICDs run on a battery that lasts from 5 to 8 years. To replace the battery, you will need minor surgery.
If you get an ICD, you have to be careful not to get too close to some devices with strong magnetic or electrical fields. These include MRI machines, battery-powered cordless power tools, and CB or ham radios. But most everyday appliances are safe.
Compare your options
What is usually involved?
What are the benefits?
What are the risks and side effects?
- Your doctor will numb the area with local anesthesia.
- You probably will spend the night in the hospital, just to make sure that there are no problems.
- You would need to have minor surgery to replace the battery after 5 to 8 years.
- You keep taking your heart failure medicine and following a healthy lifestyle.
- An ICD may lower the risk of sudden death in people who have heart failure.
- An ICD can fix a heart rate that is too fast or too slow without using a shock.
- You may have peace of mind that a dangerous heart rhythm could be fixed right away.
- Problems can happen during or soon after the procedure to place the ICD. Examples include a lead tearing the heart or a lung collapsing.
- The manufacturer could recall an ICD for a problem. If this were to happen, you might need surgery to take out the ICD and leads.
- The shock from an ICD hurts briefly.
- If the ICD gives you too many shocks, you also may need to take a rhythm-control medicine or have catheter ablation.
- You keep taking your heart failure medicine and following a healthy lifestyle.
- In some cases, you may be able to have catheter ablation to fix an abnormal heart rhythm.
- You may take a rhythm-control medicine to prevent abnormal heart rhythms.
- You avoid the risks of surgery.
- You won't worry about when the ICD might shock you.
- You could have an abnormal heart rhythm that could cause sudden death.
Personal stories about getting an ICD for heart failure
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
I have class II heart failure. I have some shortness of breath when I go for walks. My doctor said that I could have a risk of a really bad heart rhythm that could make my heart stop. We talked about an ICD. I'm a little nervous about getting shocked. But if it could save my life, it's worth it, so I'm going to get one.
Juan, age 62
I've had heart failure for a while now. My ejection fraction is 40%. It's not great. But my doctor says it's not low enough for me to think about getting an ICD. I'm taking my heart failure medicine, eating a low-salt diet, and doing everything my doctor says to do. If my ejection fraction gets lower, I will think about getting an ICD.
Marie, age 71
About 6 months ago I had a heart attack. It affected my heart's ability to pump. So I have heart failure. I've had some trouble just going shopping and taking walks. My doctor and I agreed that I should get an ICD. The type I'm going to get combines a pacemaker for heart failure and an ICD.
Lucy, age 55
My doctor told me that my heart rhythm problem might be fixed if we remove some heart tissue that causes the bad rhythm. The procedure is called ablation. It might correct the problem, so I don't need to have an ICD. I'm going to try that. If it doesn't work, then I'll talk to my doctor about getting an ICD.
Martin, age 66
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to get an ICD
Reasons not to get an ICD
I want to do everything I can to prevent a deadly heart rhythm.
I would rather use only medicine to lower my chance of a deadly heart rhythm.
I'm not worried that the ICD might shock me.
I would worry all the time that the ICD might shock me.
I don't mind having a device inside my body.
I don't like the idea of having a device inside my body.
I'm not worried about the small risks of surgery.
I'm concerned that something could go wrong with the surgery.
I'm not concerned that the ICD or the leads could break.
I'm concerned that the ICD or leads will break and I'll need another surgery.
My other important reasons:
My other important reasons:
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Getting an ICD
NOT getting an ICD
What else do you need to make your decision?
Check the facts
I need to have an ICD if I have heart failure.
- TrueSorry, that's not right. Not everyone who has heart failure needs an ICD. Your doctor may suggest an ICD if you are at risk of having an abnormal heart rhythm that could cause sudden death.
- FalseYou're right. Not everyone who has heart failure needs an ICD. Your doctor may suggest an ICD if you are at risk of having an abnormal heart rhythm that could cause sudden death.
- I'm not sureIt may help to go back and read "Get the Facts." Not everyone who has heart failure needs an ICD. Your doctor may suggest an ICD if you are at risk of having an abnormal heart rhythm that could cause sudden death.
I'll feel a painful shock if an ICD fixes a heart rhythm that could cause sudden death.
- TrueYou're right. The shock from an ICD hurts briefly. But the shock is a sign that a possibly deadly heart rhythm has been fixed. An ICD also can use painless pulses to fix a fast or slow heart rate.
- FalseNo, that's not right. The shock from an ICD hurts briefly. But the shock is a sign that a possibly deadly heart rhythm has been fixed. An ICD also can use painless pulses to fix a fast or slow heart rate.
- I'm not sureIt may help to go back and read "Get the Facts." The shock from an ICD hurts briefly. But the shock is a sign that a possibly deadly heart rhythm has been fixed.
I might need surgery again someday if the ICD breaks or if it needs a new battery.
- TrueThat's right. The ICD or the wires that attach to it could break. If that happens, you might need surgery to fix the problem. You also will need surgery to replace the battery, which lasts 5 to 8 years.
- FalseSorry, that's not right. The ICD or the wires that attach to it could break. If that happens, you might need surgery to fix the problem. You also will need surgery to replace the battery, which lasts 5 to 8 years.
- I'm not sureIt may help to go back and read "Get the Facts." If the ICD or the wires that attach to it broke, you might need surgery to fix the problem. You also will need surgery to replace the battery.
Decide what's next
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
How sure do you feel right now about your decision?
Use the following space to list questions, concerns, and next steps.
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
|Primary Medical Reviewer||Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology|
|Specialist Medical Reviewer||Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology|
- Epstein AE, et al. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation, 117(21): e350–e408. [Correction in Circulation, 120(5): e34–e35.]
- Hunt SA, et al. (2009). 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 119(14): e391–e479.
- Hernandez AF, et al. (2010). Clinical effectiveness of implantable cardioverter-defibrillators among Medicare beneficiaries with heart failure. Circulation Heart Failure, 3(1): 7–13.
- McKelvie R (2011). Heart failure, search date August 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
- Tang ASL, et al. (2010). Cardiac-resynchronization therapy for mild-to-moderate heart failure. New England Journal of Medicine, 363(25): 2385–2395.
- Van Rees JB, et al. (2011). Implantation-related complications of implantable cardioverter-defibrillators and cardiac resynchronization therapy devices. Journal of the American College of Cardiology, 58(10): 995–1000.
- Eckstein JE, et al. (2008). Necessity for surgical revision of defibrillator leads implanted long-term. Circulation, 117(21): 2727–2733.
- Kleemann T, et al. (2007). Annual rate of transvenous defibrillation lead defects in implantable cardioverter-defibrillators over a period of >10 years. Circulation, 115(19): 2474–2480.
- Baddour LM, et al. (2010). Update on cardiovascular implantable electronic device infections and their management. A scientific statement from the American Heart Association. Circulation, 121(3): 458–477.
Last Updated:September 12, 2012