Journal of the American College of Cardiology

2008 by the American College of Cardiology Foundation

Published by Elsevier Inc.

EDITORIAL COMMENT

Implantable CardioverterDefibrillator Shocks

A Double-Edged Sword?*
Merritt H. Raitt, MD, FACC
Portland, Oregon

In this issue of the Journal, Daubert et al. (1) report on

the details of inappropriate implantable cardioverterdefibrillator (ICD) shocks in the MADIT II (Multicenter Automatic Defibrillator Trial II). The MADIT II
study (2) was a primary prevention ICD trial in which
patients with ischemic cardiomyopathy and an ejection
fraction 0.30 were randomly assigned to ICD implantation or optimal medical therapy. Patients assigned to the
ICD arm had significantly improved survival. The results of
MADIT II along with the results of the SCD-HeFT
(Sudden Cardiac Death in Heart Failure Trial) (3) have led
to the recommendation that ICDs be implanted as primary
prevention for sudden death in most patients with cardiomyopathy and ejection fraction 0.30 to 0.40 (4). The
reduced mortality seen in patients with ICDs compared
See page 1357

with standard medical therapy is presumed to be on the

basis of ICD shocks terminating ventricular arrhythmias.
During a mean follow-up of 20 months, 128 of 719 patients
with ICDs in MADIT II had 393 appropriate shock
episodes and 83 patients had 184 inappropriate shock
episodes. The most common cause of inappropriate ICD
shocks was atrial fibrillation (AF), which accounted for 81
episodes (44%), followed by other supraventricular tachycardias, including sinus tachycardia leading to 67 episodes
(36%), and abnormal sensing, which was the cause of 36
episodes (20%). If appropriate ICD shocks save lives, it may
seem that a few inappropriate shocks is a small price to pay.
What is the down side of inappropriate shocks? There is
a growing medical literature on the adverse psychological
consequences of ICD shocks, whether appropriate or not.
The ICD shocks are perceived as very painful, and in one

*Editorials published in the Journal of the American College of Cardiology reflect the
views of the authors and do not necessarily represent the views of JACC or the
American College of Cardiology.
From the Division of Cardiology, Portland VA Medical Center, Portland, Oregon.

Vol. 51, No. 14, 2008

ISSN 0735-1097/08/$34.00
doi:10.1016/j.jacc.2007.12.032

study were graded 4.0 on a 0 to 5 scale (5). After an ICD

shock, patients can be immobilized, fearing that any movement or activity might trigger another shock. Multiple
shocks are the most frightening for patients, causing them
to wonder if the device is really working or if it might even
kill them (57). Those individuals who experience an ICD
shock relate greater levels of psychological distress, anxiety,
anger, and depression than those who do not (57). The
ICD shocks lead to greater psychological distress for family
members as well (7,8). Anxiety after ICD shocks remains
elevated for an unknown amount of time, and then begins to
return to normal levels as long as no further shocks occur
(9). Electrical storms, defined as having more than 3 shocks
in a 24-h period, occurs in 10% to 20% (10,11) of patients
during the first 2 years after ICD implantation. Electrical
storm sets up an adverse conditioned response that includes
avoidance of activities that may have been associated with
shocks, leading to heightened self-monitoring of bodily
functions, increased anxiety, uncertainty, and increased
dependence. In some ICD patients this leads to a reactive
depression, helplessness, and post-traumatic stress disorder.
The MADIT II data raise the concern that inappropriate ICD shocks may not only have adverse psychological consequences but may also have adverse medical
consequences. Daubert et al. (1) observed that patients in
MADIT II who received inappropriate shocks had a higher
mortality than patients who did not, with a hazard ratio of
2.29 (p 0.025). Similarly, patients with appropriate
shocks also had an increased overall mortality with a hazard
ratio between 3 and 4, with the higher hazard in patients
who had both appropriate and inappropriate shocks. Of
course this is only an association and in no way proves a
causal link between ICD shocks and an increased risk of
death. It is very reasonable to postulate that patients with
progressive heart failure and therefore increased mortality
might be more likely to develop AF and to have inappropriate ICD shocks. These same patients may also be more
likely to have ventricular tachycardia or ventricular fibrillation develop as a result of progressive congestive heart
failure and to have appropriate ICD shocks before dying of
congestive heart failure. Similarly, patients not on betablocker therapy might be more likely to have ICD shocks
for sinus tachycardia, AF, or ventricular arrhythmias with
overall higher mortality related to the consequences of not
taking beta-blockers as apposed to being a result of ICD
shocks. However, close inspection of the MADIT II data
creates reason for concern. Depending on the ventricular
rate and ICD programming, AF and sinus tachycardia can
lead to antitachycardia pacing (ATP) instead of ICD
shocks. If rapid AF and sinus tachycardia are markers for
increased mortality, then one would expect inappropriate
ATP to be associated with increased mortality as well. In
contrast to this expectation, in the MADIT II population,
although both appropriate and inappropriate shocks were
associated with an increased total mortality, appropriate and

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April 8, 2008:13668

inappropriate ATP were not. In fact, having only ATP

episodes and no shocks was associated with a trend toward
lower mortality.
How could ICD shocks contribute to increased total
mortality? The primary concern is that ICD shocks might
damage the myocardium. An acute elevation of serum
troponin is a sensitive and specific marker of myocardial
damage. Although elevated troponin levels are not infrequently seen after ICD shocks, it is impossible to determine
whether the elevation is caused by myocardial ischemia and
injury related to the tachycardia that led to the shock or by
the shock itself. At the time of implantation, the ICD is
usually tested by inducing brief (10- to 15-s) episodes of
ventricular fibrillation, which are then terminated by ICD
shocks. A few small studies have reported on troponin levels
before and after uncomplicated ICD testing and report that
troponin elevation is not infrequently seen after testing,
suggesting the ICD shocks are capable of some level of
myocardial injury (1214). This myocardial injury, although
mild, might be significant in patients who already have poor
ventricular function and congestive heart failure. More
research needs to be done, including direct studies of left
ventricular function and neurohumoral activity before and
after ICD shocks, to give us better idea of what exactly the
adverse effects of ICD shocks might be.
It is also possible that there are adverse effects of ICD
shocks that could lead to increased mortality that are not the
result of direct damage of the myocardium. I have already
outlined the adverse psychological effects of ICD shocks.
These adverse effects include anxiety and depression. Both
anxiety and depression are known to be associated with a
worse prognosis in patients with congestive heart failure
(1517). Could the adverse psychological effects of ICD
shocks lead to anxiety and depression and a cascade of
events that culminates in an increased risk of death in
patients with congestive heart failure?
Whether or not there is a causal relationship between
ICD shocks and the associated increase in mortality, the
psychological effects of shocks alone are reason to do
everything possible to reduce the incidence of appropriate
and inappropriate shocks. The ICD programming is the
first line of defense. In the MADIT II trial AF was the most
common cause of inappropriate shocks, and patients who
had the stability detection algorithm programmed on in
their ICDs, which is designed to prevent shocks for AF,
were less likely to have inappropriate shocks (1). There are
other detection algorithms available on many ICDs that
evaluate the morphology of tachycardias or the timing and
frequency of atrial and ventricular activation to prevent
inappropriate shocks for supraventricular rhythms such as
AF and sinus tachycardia. These algorithms help to prevent
inappropriate shocks.
The next step in reducing ICD shocks is programming to
use ATP instead of shocks whenever possible. Currently
many electrophysiologists do not routinely program ATP in

Raitt
Editorial Comment

1367

patients with ICDs. By protocol ATP was not turned on in

the SCD-HeFT (3). Arguing in favor of the utility and
efficacy of ATP is the Pain Free II study, which showed that
aggressive use of ATP even for very fast episodes of
ventricular tachycardia was effective and reduced the risk of
shocks (18). Some physicians are worried that, if ineffective,
ATP will delay tachycardia termination. In response, one
ICD manufacturer has introduced a feature in which ATP
is used to try to terminate ventricular arrhythmias while the
capacitor is charging in preparation for an ICD shock. If the
ATP works, the shock is aborted; if not, the shock is not
delayed. Given the adverse psychological effects of ICD
shocks and the possibility that shocks may increase mortality, these programming features should probably be used
whenever possible. It is less clear whether medical therapy
can reduce the risk of ICD shocks. If, in fact, exacerbations
of congestive heart failure lead to ICD shocks, then perhaps
more aggressive treatment of congestive heart failure in
patients with ICDs and use of congestive heart failure
monitoring protocols built into some ICDs might prevent
some appropriate and inappropriate shocks. It is less clear
whether empiric antiarrhythmic therapy will prevent ICD
shocks, and such therapy cannot be recommended at this
time because of the risk of proarrhythmia and the cardiac
and noncardiac side effects of antiarrhythmic medications.
The final question is whether shocks related to ICD testing
might have a detrimental effect on patients and whether
defibrillation testing should be done only in a limited subset
of patients or at all (19). Some have suggested given the
efficacy of modern ICDs that testing is not needed. Others
have proposed alternative methods of testing ICD efficacy
that require no or fewer ICD shocks. The potential benefits
of these strategies deserve further study.
The ICD shocks may well be a double-edged sword.
They have been shown to prolog life as primary and
secondary prevention of sudden death in patients with
severe cardiomyopathy (3,4) and in patients with a history of
life-threatening ventricular arrhythmias (20). However, the
shocks have important detrimental psychological effects,
and the results of the analysis of inappropriate shocks in the
MADIT II study reported in this issue of the Journal (1)
show that inappropriate shocks are common and suggest
that the same shocks that save lives by terminating ventricular arrhythmias may paradoxically increase the risk of
death. Additional research needs to be done to explore the
potential adverse effects of ICD shocks. In the meantime,
ICD programming options currently available should be
used to reduce the risk of inappropriate shocks, and ATP
should be used instead of shocks whenever possible to
terminate ventricular arrhythmias.
Reprint requests and correspondence: Dr. Merritt H. Raitt,
3710 SW U.S. Veterans Road, Portland, Oregon 97239. E-mail:
merritt.raitt@va.gov.

1368

Raitt
Editorial Comment

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