This week's JAMA study on implantable cardiac defibrillators that don't fall within recommended guidelines from the American College of Cardiology , American Heart Association and Heart Rhythm Society is a reminder, as a UAB heart doctor says, that medicine is not always black and white; there are gray areas that don't always mesh with rigid adherence to guidelines.

UAB electrophysiologist H. Thomas McElderry, M.D ., says while most defibrillator implants at UAB fall within the professional societies' recommended courses of action there are instances where they are indicated and justifiable even though the use falls outside the guidelines.

"A good example of ICD implant use outside the guidelines is a patient with class IV heart failure who is awaiting transplant. We often implant ICDs in these patients to prevent them from dying suddenly from an arrhythmia while waiting for a heart," McElderry says.

Following the guidelines is important but, McElderry says, so is a physician's judgment.
"We need to remember that medicine is still a practice and not all patient needs fit within guidelines. Data and guidelines are important; however, treatment decisions have to be made at the patient level, on a patient-by-patient basis."

McElderry encourages people who have been told they need a defibrillator to consult an electrophysiologist before making a final decision. Electrophysiologists are cardiologists who have additional education and training in diagnosing and treating abnormal heart rhythms and are the most familiar with treatment guidelines and exceptions.