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Comment & Response
July 31, 2019

Conversion, Compromise, and Conversation—Moving to a Sensible Middle When Addressing Implantable Cardioverter-Defibrillator Therapy—Reply

Author Affiliations
  • 1Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Cardiol. Published online July 31, 2019. doi:10.1001/jamacardio.2019.2610

In Reply We thank Gimbel and Wilkoff for their interest in our Viewpoint.1 Their letter highlights 2 interesting aspects of managing patients with implantable cardioverter-defibrillators (ICDs) as their goals evolve over time.

One is the unfortunate terminology characterizing transition from ICD therapy to pacing alone as a downgrade. We agree that this is needlessly value laden and even cynical and unlikely to promote productive shared decision-making with patients. Careful qualitative research has shown that cognitive biases can influence patient choices around ICDs,2 including decisions to forego therapy.3,4 The ongoing A Multicenter Trial of a Shared Decision Support Intervention for Patients Offered Implantable Cardioverter-Defibrillators (DECIDE-ICD) study, for which one of us (D.B.K.) is a co-investigator, may further expand our understanding of patient perspectives around ICD generator placement procedures. In our discussions with patients about this option, we prefer to characterize conversion of ICD therapy to pacing as an adjustment of device features that are important and relevant to the patient’s health care goals.

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