Primary care management of the heart failure patient requiring an implanted cardioverter defibrillator

Heart failure is a chronic, progressive disease that remains on the rise partially due to improvements in preventing cardiac related mortality from other causes. Implanted cardioverter defibrillators are indicated for patients that are at high risk for sudden cardiac death from ventricular arrhythmias (primary prevention), or for those who have survived a cardiac death (secondary prevention). Guidelines suggest simple and easy to follow directions for providers to determine which patients would be eligible to be considered for a device. However, despite national guidelines, research supporting cost effectiveness, and a repeatedly demonstrated reduction in mortality with device therapy, referral and utilization of ICDs remain low, with most of the non-referral and underutilization rates identified within the primary care provider group. In addition, for those patients who do receive ICDs, advanced care planning with consideration of deactivation of the device at end-of-life is rarely completed, leaving many patients at risk of undignified and painful shocks delivered within the last hours to days of life. This integrative review seeks to explore: Primary care management of the heart failure patient requiring an implanted cardioverter defibrillator. A comprehensive search of the literature was undertaken and 15 articles were selected for inclusion This review establishes that ICDs are effective and relatively low-risk devices that have significant mortality benefits, and patients with HF should be screened routinely for eligibility for the device in order to help prevent SCD. Furthermore, patients who receive an ICD should complete an informed advance care directive which includes directions for management of the ICD at end-of-life. ICD management, while often deferred to specialists, requires a collaborative approach and consistent evaluation from the patient’s primary care provider, as it has the potential to influence all aspects of patient’s quality of life, as well as quality of end-of-life care. Recommendations for practice, education, further research, and policy have been made to support the role of primary care providers, such as Nurse Practitioners, in the management of HF patients requiring an ICD.