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The ABCs of ICDs

Living with a Pacemaker or Defibrillator

Like a metronome, a healthy heart beats at a regular rhythm. But for those with heart arrhythmias or irregular heartbeats, the heart may beat too fast (tachycardia) or too slow (bradycardia). These conditions can lead to serious health problems such as stroke, cardiac arrest or sudden cardiac death.

To help resolve this condition, doctors may recommend an Implantable Cardioverter Defibrillator (ICD) or a pacemaker for patients with life-threatening arrhythmias who cannot be effectively treated in other ways. ICDs are devices smaller than the size of a pager that connect to the heart. Pacemakers today may be not much bigger than a silver dollar.

When is an Implantable Device Needed?

A pacemaker is typically used to correct a slow heart rate. Implanted beneath the skin in the chest just below the collar bone, it is wired to the heart to send out electrical impulses when the heart rate is too slow. Sometimes, medications used to remedy fast heartbeats work so well that a pacemaker is needed along with the drugs to ensure that the heartbeat is not too slow.

An ICD is programmed to detect potentially life-threatening, abnormally rapid heart rhythms and correct them by delivering a jolt of electricity. In addition, ICDs may restore the normal rhythm by actually pacing the heart briefly at a slightly faster rate. Implanted under the skin of the chest or abdomen, an ICD's electrode wires are connected to the right chambers of the heart.

Electrophysiologists (cardiologists who specialize in diseases affecting the electrical system of the heart) implant ICDs and pacemakers in a safe and relatively minor procedure that takes about 60 minutes.

These devices consist of a battery (which can last 6 to 10 years), electronic circuitry and energy delivery components, which are sealed in a small case. No need to worry about battery life; your doctor uses a tool that detects very early signs that the battery is running down, and replacement is usually a minor surgical procedure.

Life Goes On

A few lifestyle changes are required, but in many ways, life goes on as normal. Most people leave the hospital the day after surgery and are cautioned to avoid reaching up or lifting weight over five pounds with the side where the surgery occurred for about six weeks. Most patients resume driving after a week or two and feel back to normal (or even better than usual) very quickly.

Any contact with water is fine - your ICD or pacemaker is completely protected. The American Heart Association recommends that you should avoid placing pressure on the area of your chest where the device is implanted. Some women opt to wear a small pad over the device to alleviate pressure from their bra straps.

Alfred E. Buxton, MD

To learn more about life with implantable devices, Heartmail spoke with Alfred Buxton, MD, Director of the  Clinical Electrophysiology Laboratory at Beth Israel Deaconess Medical Center's CardioVascular Institute.

"Drastic, life-altering limitations due to the implantation of a device are rare," Buxton says. "Activities are usually limited more by a patient's underlying heart disease than by the implanted device."

Is Exercise Okay?

Exercise usually does not put you at risk, but intense, repeated upper body exertion from activities like weight lifting, rowing or swimming can harm the device by damaging the wires that lead to the heart. Contact sports such as football or hockey should also be avoided.
At the same time, Dr. Buxton stresses, exercise is important for heart patients.

"Though we suggest that people with devices try to avoid repetitious upper body movement, it's also difficult to know exactly why a lead [wire connected to the heart muscle] does fracture," he says. "It could be due to physical activity or it could be unrelated. In almost all cases, the benefits of exercise outweigh the risks."
While patients express concern about sexual activity, there is no reason not to resume sexual activity once you have recovered from the surgery to implant your device. Most physicians recommend waiting about four weeks after surgery. In addition, a study published in the Journal of the American Medical Association found that regular, moderate exercise, like that associated with sexual activity, was connected to a decreased risk of heart events in patients with a prior history of heart disease.
Infrequently, an ICD shock is delivered during exercise. When this occurs, the device may require a programming adjustment to ensure that it will respond to an abnormal rhythm and not to the body's normal response to exercise.

Electronic Devices to Avoid

Some machines and equipment that operate on electromagnetic current can interfere with the electrical pulse generated by your pacemaker or ICD. According to the American Heart Association, using the following devices is okay but prolonged or direct exposure to them should be avoided:

  • Anti-theft systems (often found in entrances or exits of businesses)
  • Electrical generators
  • Large motors, such as those found on boats or cars
  • Metal detectors for security
  • Powerful magnets
  • Arc welding equipment

Cell phones: These generally operate on less than 3 watts and don't appear to affect implanted devices. However, according to the AHA, new frequencies made available by the Federal Communications Commission (FCC) may interfere with normal pacemaker function. 
Digital audio headsets: Most headphones for MP3 players and iPods contain magnetic material that causes interference when placed too close to a pacemaker or ICD. The AHA recommends that headphones (both earbud and clip-on types) be kept at least 1.2 inches (3 cm) away from a pacemaker or ICD.
The best practice, according to Buxton, is to use caution when encountering items that have the potential to interfere with an ICD or pacemaker.

"The best way to limit risk is to limit exposure," he says. "Always walk through airport metal detectors and store security tag detectors quickly, and if you have a digital audio player, make sure you carry it in a pocket further away from your device. The same goes for cell phones. Always hold your cell phone to the ear opposite the side of the body where the device was implanted."

Medical procedures that require caution: Equipment used in some medical procedures can interfere with or damage ICDs and pacemakers. Be sure to notify your doctor before undergoing any of the following procedures:

  • Magnetic Resonance Imaging (MRI)
  • Shock-wave lithotripsy (used in treating kidney stones)
  • Electrocauterization (used to stop bleeding during surgery)
  • Short-wave or microwave diathermy (high-frequency, high-intensity signals used for physical therapy)
  • Therapeutic radiation (used for cancer treatment)

Watch for Signs of Infection

The potential for infection is a significant concern for those with ICDs or pacemakers. Another study published in JAMA concluded that the occurrence of infection in patients with an ICD or pacemaker increased by 210 percent between 1993 and 2008. Of 2,760 heart infection cases in the study, 177 infections of the heart valve or lining (endocarditis) were directly attributed to the patient's pacemaker or ICD.

These devices can make the heart susceptible to bacterial infections, and those with a device who develop endocarditis are at increased risk of death because their hearts are already compromised.
One reason the morality rate is higher in endocarditis patients with pacemakers or ICDs is that many doctors are unsure how to treat the problem once infection sets in, according to Buxton. At that point, it's often too late for antibiotic medication. The outlook for full recovery from infection is best when the device is removed.

"When you have a device such as a pacemaker or an ICD, the prosthetic material interferes with the body's normal defenses for fighting infection," says Buxton. "Physicians who are unfamiliar with how best to treat the infection may falsely assume their patients are improving with antibiotics, but the best rate of survival is in those who undergo a removal of the device."

Signs of infection can include difficulty breathing, fever, a dry cough, swelling of the feet or legs, weight gain, or worsening pain or redness at the site of the incision. If you have an implanted cardiac device and experience any of these symptoms, contact your doctor immediately.

Awareness is Important

While getting an ICD or pacemaker doesn't mean a huge change in lifestyle, it does mean that you will need to have your device checked regularly for its function and battery life.
If you have a new ICD implanted, you will likely have an appointment about one week after discharge, again in two months, and then every three to six months. You'll be given detailed instructions about what to do if your device delivers a shock. New pacemaker patients generally have a check-up about four weeks after surgery. After that, pacemaker checks are done by telephone (transtelephonic monitoring) every month or two using a special device that your doctor will provide. You'll also visit your doctor's office once or twice a year.

Be attentive to your environment and any nearby devices that may affect your pacemaker or ICD. Make sure medical professionals are aware of your device before they start any test or procedure. Symptoms of a device malfunction can include dizziness, difficulty breathing, swelling in the limbs, chest pain, or twitching. If you suspect interference with your pacemaker, simply move away or turn off the equipment. Your pacemaker usually won't be permanently damaged and will resume its normal activity. You should, however, report the event to your cardiologist to determine whether you need medical follow-up.

It's important to carry an ID card that shows you have an implanted cardiac device. The AHA offers an online pacemaker ID card that you can print at home. Another option is to wear a Medic Alert bracelet or necklace that is engraved with data such as the type of pacemaker or ICD you have and an emergency contact and phone number.

Awareness is truly the name of the game when it comes to living with ICD or pacemaker. By monitoring your health and your surroundings and following your doctor's recommendations, you can pick up life where you left off before you had the device - without missing a beat!

Above content provided by the CardioVascular Institute at Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.

Posted August 2012