Guidance for ICD Replacement

Dr. Sidney Goldstein points out that recalls of implantable cardioverter defibrillators can have a chilling effect on prophylactic ICD implantations, and have heightened the need for better risk stratification to select patients likely to benefit from ICD prophylaxis (“When Is a Recall Not a Recall?” Heart of the Matter, November 2006, p. 2).

In the pivotal Sudden Cardiac Death in Heart Failure Trial (SCDHeft), fewer than 10% of patients receiving prophylactic ICDs had a mortality benefit during a 5-year follow-up.

We proposed a four-step algorithm for determining which patients with a recalled ICD should have their prophylactic ICD system revised or replaced (Am. J. Cardiol. 2006;98:1291–93), using the following questions:

Is the patient too sick to have his ICD system revised?

Has a sustained ventricular tachyarrhythmia occurred since implant?

Is the left ventricular ejection fraction still less than 0.36?

Is the microvolt T-wave alternans test abnormal?

This same four-step method should help to select patients for ICD prophylaxis as well. Recently, the ABCD trial proposed a combination of MTWA and electrophysiologic studies to select patients for ICD prophylaxis (Circulation 2006;114:2426 [abstr]). These approaches promise to improve selection of patients for ICD prophylaxis and management of patients facing ICD recalls.

Robert E. Kleiger, M.D.

St. Louis

J. Thomas Bigger, M.D.

New York

No Standardization Without Investment

The current situation with electronic health records reminds us of the state of affairs at the beginning of the automobile industry when several dozen brands competed for market share. Only a few were left standing by the 1940s (“Panel Certifies First 22 Ambulatory EHR Products,” September 2006, p. 21).

I will not invest in an EHR product that has not been standardized. But standardization would require a large up-front investment for which no third-party payer is willing to pick up the tab. I already capture all of my revenues with custom-made paper progress notes and by keeping up to date with billing issues.

Ely Robert Tandeter, M.D.

Chicago Ill.

President's Veto Will Cost Lives

President Bush's recent veto of federal funding for embryonic stem cell research is dismaying but not surprising, considering the continual pandering among Republicans to the Religious Right (“Disappointment Follows Bush's Veto of Stem Cell Research Bill,” September 2006, p. 22).

For Bush to use the first veto of his presidency to prevent federal research on a technology that may hold the best promise in fighting disease is the sacrifice of actual human lives to discarded clumps of cells. The only opposition to this funding is religiously based and therefore should have no place in our governmental decision-making process. Physicians must not sit in silence, and they must not allow “snowflake” children and other techniques reminiscent of anti-abortion activists to rattle their determination.

Amesh A. Adalja, M.D.

Butler, Pa.

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