{"id":40533,"date":"2013-12-18T12:13:00","date_gmt":"2013-12-18T17:13:00","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=discussion&p=40533"},"modified":"2013-12-29T16:24:51","modified_gmt":"2013-12-29T21:24:51","slug":"doc-do-i-really-need-a-new-battery","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/12\/18\/doc-do-i-really-need-a-new-battery\/","title":{"rendered":"Doc, Do I Really Need a New Battery?"},"content":{"rendered":"

A 45-year-old man with nonischemic cardiomyopathy, diagnosed\u00a08 years ago, presents for annual follow-up.\u00a0A transthoracic echocardiogram (TTE), taken 3 years ago, showed an LV ejection fraction of 25%. Since then, the patient has improved a great deal and now has barely any signs or symptoms of heart failure.\u00a0Repeat TTE right before the current visit showed an LVEF of 50% and no significant abnormal findings.<\/p>\n

An electrophysiologist who saw the patient a week before his current visit noted that his implantable cardioverter-defibrillator (ICD), which was placed 6 years ago but has never fired, is near the end of its life and needs a new battery. The battery replacement is scheduled for 1 month from now, but the patient is unsure whether to bother getting a new battery. He notes that his heart function is close to normal and wants to know if he should still take his heart failure medications (metoprolol, lisinopril, and spironolactone).<\/p>\n

What would you advise this patient \u00ad\u2014 and why?<\/b><\/p>\n

1. Replace the ICD battery; keep taking the heart failure medications.<\/p>\n

2.\u00a0Do not replace the battery; keep taking the heart failure medications.<\/p>\n

3. Do not replace the battery; discontinue the heart failure medications.<\/p>\n

4. Another option<\/p>\n

 <\/p>\n

RESPONSE:<\/strong> December 22, 2013<\/em>
\nJames Fang, MD<\/a>
\nI recommend option 1: Replace the ICD battery and keep taking the heart failure medications. Although the improvement in ventricular function is dramatic, an LVEF of 50% is, in fact, not normal. Moreover, the case makes no mention of ventricular remodeling \u2014 is the ventricle still dilated?<\/p>\n

It is important to distinguish true myocardial recovery (true normalization of cardiac function after a reversible insult) from myocardial disease that is in remission. When there is remission, as in this case, myocardial dysfunction is still demonstrable (lack of inotropic or chronotropic reserve, elevated biomarkers, remodeling, abnormal ECG findings), and patients may still experience clinical events, including heart failure\u2013related hospitalization and mortality. MRI imaging can also be helpful, in that persistent myocardial fibrosis strongly indicates a disease in remission. Nevertheless, in the case of true recovery (as evident from a completely normal ECG, echocardiogram, biomarkers, and so on), a trial of medication withdrawal with appropriate surveillance may be considered.<\/p>\n

 <\/p>\n

FOLLOW-UP: <\/b>December 30, 2013<\/em><\/p>\n

Tariq Ahmad, MD, MPH<\/a><\/p>\n

We discussed the various options with the patient. He ultimately chose option 2:\u00a0Do not replace the battery; keep taking the heart failure medications. He reported feeling \u201c100%,\u201d going to the gym regularly, and working full time as a computer analyst \u2014 all without incident. He agreed to follow up in a year to have a repeat echocardiogram and laboratory testing.<\/p>\n

On his return clinic visit, approximately 1 year from the discussion, his echocardiogram parameters were unchanged and his N-terminal pro-BNP level was within normal limits. He had not experienced any signs or symptoms of cardiac arrhythmia or heart failure and wanted to continue to stave off a battery upgrade. He said he didn\u2019t mind continuing the medications, noting \u201cIf it isn\u2019t broken, don\u2019t try to fix it.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

A 45-year-old man with nonischemic cardiomyopathy, diagnosed\u00a08 years ago, presents for annual follow-up.\u00a0A transthoracic echocardiogram (TTE), taken 3 years ago, showed an LV ejection fraction of 25%. Since then, the patient has improved a great deal and now has barely any signs or symptoms of heart failure.\u00a0Repeat TTE right before the current visit showed an […]<\/p>\n","protected":false},"author":406,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13],"tags":[287,448,2084],"class_list":["post-40533","post","type-post","status-publish","format-standard","hentry","category-electrophysiology","tag-heart-failure-2","tag-icds","tag-nonischemic-cardiomyopathy"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/40533","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/406"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=40533"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/40533\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=40533"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=40533"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=40533"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}