Half of implantable cardioverter-defibrillator patients remain at risk of painful shocks in the last moments of life

Abstract

Abstract Background Patients with implantable cardioverter-defibrillators (ICDs) are at risk of receiving painful shocks near the end of life due to ongoing tachytherapy. Position papers of various international societies emphasize the need for advance care planning and timely deactivation of tachytherapy. This study aims to assess the real world practice of deactivating ICD tachytherapy prior to death over a consecutive 18-year period and strives to identify areas for improvement. Methods Medical records were reviewed of all patients who were carriers of an ICD or CRT-D and under follow-up at our university medical center. Those who deceased between 2006 and 2023 were identified from the municipal civil registry and their follow-up data were extracted from electronic patient records. The cause of death and status of ICD therapy at the time of death was analysed. Results During the study period, 1724 patients with an ICD expired (mean age 73 ± 10 years; 265 (15%) females; 1396 (81%) primary prevention; median time from initial ICD implantation 7.5 [interquartile range: 4 to 12] years. Baseline characteristics of patients who had tachytherapy deactivated prior to death did not differ significantly from those who did not. Overall, 769 (43%) devices were deactivated before death. The proportion of patients with deactivated tachytherapy prior to death gradually increased over time, surpassing to just >50% in the past decade (p<0.001), Figure 1. Causes of death differed between the two groups (p=0.022), Figure 2. The majority of patients with deactivated tachytherapy prior to death died due to: heart failure (38%); non-cardiac causes (23%) e.g. myocardial infarction or valvular disease; malignancy (23%) and other non-cardiac causes such as infectious diseases, stroke and trauma (31%). However, substantial proportions of patients dying from causes that could potentially be identified as an end-of-life phase, remained at risk of shocks in the last moments of life due to active tachytherapy (30% heart failure, 11% malignancy, 25% other non-cardiac causes). Conclusions The rate of patient with deactivated ICD tachytherapy before death doubled within the initial 4 years of the study period and more or less stabilized thereafter, thus leaving nearly half of ICD patients susceptible to painful shocks in their final moments of life. This underlines the necessity of timely advance care planning, including discussions regarding discontinuation of ICD therapy during the end-of-life phase.