- The Washington Times - Monday, May 26, 2003

Jerome Ramsey, who spends his winters in Bethesda, knows what it feels like to be knocked literally off his feet. Due to a rapid heart rate, he has been shocked on multiple occasions through a medical device implanted in his chest.

“In September 1997, as I was gardening, without any kind of forewarning, I was suddenly knocked to the ground,” says Mr. Ramsey, who lives in Johnson City, N.Y., the rest of the year. “I was puzzled for a moment, then realized it must have been my device. … I realize the device is like having my own ER with me all the time. And that’s a good thing.”

Multiple therapies are available for people with irregular heartbeats, including various treatments and implantable medical devices. These options help to reduce the number of deaths from sudden cardiac arrest. Approximately 400,000 such deaths occur in the United States annually.

In 1995, doctors placed an implantable cardioverter-defibrillator inside Mr. Ramsey’s chest after a severe episode of ventricular tachycardia, which is when the heart’s bottom chambers beat too quickly. Mr. Ramsey’s heart had reached a rate of 200 beats a minute.

When the heart experiences ventricular tachycardia, less blood is pumped to the body and the brain. If the condition isn’t treated properly, it can be life-threatening. Now, Mr. Ramsey, 73, relies on the implantable cardioverter-defibrillator, the same type of device Vice President Richard B. Cheney has, to shock his heart if it starts to beat too quickly.

The device, which is a little smaller than a beeper, also contains a pacemaker, which stimulates the heart if it beats too slowly. Pacemakers also can be implanted as separate devices.

So far, Mr. Ramsey’s implant has gone off about eight times, which has undoubtedly extended his life. However, since being shocked is the equivalent of being kicked in the chest or hit with a baseball bat, it has not been a pleasant experience.

Sudden cardiac death is now the No.1 fatality in the United States, more than heart attacks, says Dr. Cynthia Tracy, chief of the division of cardiology at Georgetown University Hospital in Northwest. According to the American Heart Association, approximately 225,000 people die of heart attacks per year in the United States.

Sudden cardiac death can occur in the presence of a heart attack, but also may result from a variety of cardiac reasons and is generally related to a lethal heart rhythm problem. When experiencing a heart attack, one of the coronary arteries that supplies the heart muscle with blood closes. This results in damage of the heart muscle.

Signs that a patient needs an implantable cardioverter-defibrillator include prior heart attacks or decreased function of the left ventricle, the heart’s main pumping chamber. These symptoms are found in about 4 million people in the United States.

In fact, hardening of arteries, which is associated with certain types of heart disease, can lead to heart muscle damage that becomes the catalyst for serious arrhythmias. This could cause sudden cardiac death, which is caused by rapid heartbeats, without a heart attack taking place. Further, serious arrhythmias also can occur before or after a heart attack. They can happen for a number of other reasons as well, some of which are more serious than others.

For instance, a person with a structurally normal heart experiencing arrhythmias may have idiopathic ventricular tachycardia, which may be caused by irritable areas in the right or left ventricle.

In general, the condition is not life threatening. Most patients don’t lose consciousness during episodes when their heart rates increase. Also, the risk of losing effective heart pumping function is low with this condition.

“A lot of those people can be very nicely treated with medication, or it will spontaneously go away,” Dr. Tracy says. “If the heart is structurally normal or near normal, the arrhythmia is less important.”

If medication, such as beta-blockers, does not correct the problem, radiofrequency catheter ablation often cures the condition. This procedure cauterizes the abnormal tissue in the heart that is causing the irregular beats. A catheter with a small electrode at the tip that delivers radio frequency waves is run through a vein in the groin to the heart.

When the catheter is touched to the abnormal heart tissue, it alters the way impulses travel throughout the organ, which usually results in a normal heartbeat. The treatment is often preferred by patients, especially when the individual is young, rather than lifelong drug therapy, which can have negative side effects.

Even those people who have abnormally structured hearts with more serious arrhythmias can benefit from a radiofrequency catheter ablation. For instance, Mr. Ramsey had the procedure even after receiving his implantable cardioverter-defibrillator. The combination of the ablation and the device has helped Mr. Ramsey tremendously.

Sometimes people experiencing arrhythmias also have mechanical problems in the heart. An implantable cardioverter-defibrillator with the ability to resynchronize the heartbeat can help them. This cardiac resynchronization therapy is what Jack Nishimura, 76 of Woodbridge, Va., received in January.

The miniature machine implanted in his chest paces both the left and right ventricles simultaneously, whereas the typical pacemakers and defibrillators only pace the right side of the heart. This action has the effect of resynchronizing the muscle contraction in the left ventricle, and thus improving the efficiency of the weakened heart.

“It’s part of my body, and I don’t even realize it’s inside me,” Mr. Nishimura says. “I used to be out of breath when I walk up the steps. Now I can walk up the steps. I can do a lot of things that I couldn’t do before I got my operation.”

Other devices available for patients with irregular heartbeats include pacemakers, which help control slow heart rates, says Dr. Adam Strickberger, an cardiac electrophysiologist at the Washington Hospital Center in Northwest. Symptoms of someone needing a pacemaker include passing out or being out of breath. However, these signs could also appear in someone needing a cardioverter-defibrillator.

Pacemakers have been around since the 1950s. Since then, their size has decreased and their sophistication has improved. If needed, they can be reprogrammed from the surface of the skin. After about eight years, the battery will probably have to be replaced, which can be done as an outpatient procedure. The defibrillators can be reprogrammed in a similar process.

“The machines are smart,” he says. “They have sensors inside the devices. The sensors either monitor respiratory rate or movement of the body. They can adjust the heart rate to the person’s physical state or stimulate the heart so the heart beats faster.”

Since the implantable medical devices can be rather costly, Dr. Gordon F. Tomaselli, professor of medicine in the division of cardiology in electrophysiology service at Johns Hopkins University in Baltimore, says it is better to prevent the need for the device in the first place.

If everyone in the United States with hardened arteries who doctors believe need an implantable cardioverter-defibrillator received one, it would cost the health care economy in excess of $100 billion just for the hardware, he says. This cost does not include physician or laboratory fees.

Right now, some people who doctors think should have the devices aren’t receiving them because of the high price, says Dr. Tomaselli. Despite the cost, the medical community is encouraging all insurance companies to cover the procedures in order to save lives.

Medical researchers also are trying to come up with better indicators for individuals who definitely need an implantable device, which would eliminate giving a machine to someone who really doesn’t need one.

“If we could be competent enough to say at least 10 percent of the people don’t need one, it would save $10 billion,” Dr. Tomaselli says.

Further, anyone with a prior heart attack, high cholesterol or hardening of the arteries should take one aspirin a day, unless otherwise directed by a doctor, he says. People also need to quit smoking, avoid foods high in cholesterol and triglyceride fats, exercise regularly, and monitor their blood pressures.

“If we’re using these devices we’re too late,” he says. “Prevention is the way to go. … If you have familial risk factors, there’s not much you can do, but at the first sign of symptoms you need to seek treatment.”

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