ICD s SUPPORT AND REHABILITIATION - A MULTIDISCIPLINARY APPROACH

1.  ICD�s � SUPPORT AND REHABILITIATION - A MULTIDISCIPLINARY APPROACH

2. Outline The Multi- Disciplinary Team (MDT) What is an ICD Who needs them? Programming the ICD Diversity of patient needs The multi disciplinary team approach to providing support and cardiac rehabilitation Future Developments

6. How do they work? Therapies are tailored to the individual Low energy cardioversion High energy cardioversion Anti Tachycardia Pacing Bradycardia Pacing

7. WHICH PATIENTS NEED AN ICD?

8. Patients at risk of sudden cardiac death

9. Nice Guidance On ICD Implantation Primary Prevention: for patients with A history of previous (more than 4 weeks) MI and either Left ventricular dysfunction with an LVEF of less than 35% (no worse than class111 of the New York Heart Association functional classification of heart failure), and non sustained VT on holter monitoring and inducible VT on E.P testing or - left ventricular dysfunction with an LVEF of less than 30% (no worse than class111 of the New York Heart Association functional classification of heart failure) and - QRS duration of equal to or more than 120 ms

10. Nice Guidance On ICD Implantation Primary Prevention: those who have - a familial cardiac condition with a high risk of sudden cardiac death, including long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or arrhythmogenic right ventricular dysplasia (ARVD), or have undergone surgical repair of congenital heart disease

11. Nice Guidance On ICD Implantation Secondary Prevention : For patients who present, in the absence of a treatable cause with one of the following: Having survived a cardiac arrest due to either ventricular tachycardia (VT) or ventricular fibrillation (VF)Cardiac arrest due to either V.T or V.F. Spontaneous sustained VT causing syncope or significant haemodynamic comprise Sustained VT without syncope or cardiac arrest, and who have an associated reduction in ejection fraction (LVEF of less than 35%) ejection fraction of less than 35% (no worse than class111 of the New York Heart Association functional classification of heart failure)

12. Patients with Heart Failure  Cardiac Resynchronisation and Defibrillation devices (CRT-D) Selection criteria - NYHA III & IV - Optimal medical therapy (ACE inhibitor, Beta-blocker and diuretic) - QRS >120msec, PR interval >150msec Ejection fraction<35% COMPANION 2004 � 36% risk reduction of all cause mortality Chronic heart failure. NICE Clinical Guideline No. 5 (2003). Available from: www.nice.org.uk/CG005 

13. Why a MDT Approach?

14. Why a MDT approach?  Not age specific Co morbidities Familial conditions Risk of SCD Patient management will take place in various care settings Diverse needs Psychological implications

15. A PATIENT JOURNEY Out of hospital arrest Transfer to tertiary centre Assessment for ICD � various tests performed Decision made to implant ICD Reiterate and expand on information already given - procedure explained, implications for future lifestyle (driving, employment etc) Normal living can be resumed � think positive! Procedure performed Family screening may be required Patient discharged the following day post implant Follow up - may be routine, may be complex! may need input from numerous organisations!

16. Psychological Implications Some examples - Facing up to own mortality - Fear of Shock � reluctance to exercise - Loss of independence- driving restrictions, employment issues - How it may it affect other family members - familial conditions - How family members/carers may react - over protection etc

17. ICD Support and Rehabilitation Services Provision of information Assessment of patients/families pre and post implant (Hospital Anxiety and Depression scale) Referral to other disciplines as appropriate Communicate with HCP�s in primary care Life long follow up Routine follow up � 1 week, 2 weeks, 6 weeks, 6 months

18. Continuous Support 24hour support service/drop in service Support provided for patients/carers and other health care professionals Buddy system 3 monthly patient support group meetings � format has changed due to increase in numbers (support groups and link nurses in other areas)

19. Practical issues Insurance Holiday advice/medic alert Employment � on site field testing Assistance with benefit claims/tribunals

20. Exercise Programmes for patients with ICD�s at JCUH Not currently available for all patients with ICD�s but plans to expand the service in the near future Slightly modified exercise programme � caution used in arm/shoulder exercises Patient can be anxious about receiving shock from the device during excercise Device settings taken into consideration Close monitoring and supervision Substantial benefit to patient � increase in confidence

21. Education Patients and Carers Other health care professionals GP�s and others in primary care Ambulance crew Heart Failure Nurses HCP�s in Secondary care Accident and Emergency staff Mortuary technicians All health care professionals involved in the management of patients with ICD�s Employers

22. Future Developments Continue to develop the existing service in line with national policy and guidance Further develop services in secondary and primary care Data collection system Increase in number of appropriately skilled staff available in all areas Arrhythmia Care Co ordinator - strengthen further the close collaboration at all levels of the health care service

23. Why a MDT Approach? � A MDT approach is key to ensuring improved service to those with cardiac arrhythmias and to the delivery of interventional therapies. Better access to effective treatment in primary, secondary and specialist settings will reduce hospital admissions, reduce mortality and improve the quality of life for patients and their families� The National Service framework for Coronary Heart Disease- Chapter Eight: Arrhythmias and Sudden Cardiac Death

25. Useful Links The National Service Framework for Coronary Heart Disease � Chapter Eight: Arrhythmias and Sudden Cardiac Death The Arrhythmia Alliance - www.arrhythmiaalliance.org.uk Heart Rhythm UK - www.hruk.org.uk Implantable cardioverter defibrillators for arrhythmiasReview of Technology Appraisal 11NICE Technology Appraisal Guidance No. 95 (2006)Available from www.nice.org.uk/TA095 Chronic heart failure. NICE Clinical Guideline No. 5 (2003). Available from: www.nice.org.uk/CG005 Bristow MR, Saxon LA, Boehmer J et al 2004; Cardiac Resynchronisation therapy with or without an Implantable Defibrillator in Advanced Chronic Heart Failure NEJM,Vol 350: 2140 - 2150 Heart failure � biventricular pacing (cardiac resynchronisation). NICE Technology Appraisal (expected date of publication March 2007)