A Wearable Defibrillator After a Heart Attack, Barely Worn: What Comes Next
A single patient wearing a device meant to protect him for only about half of each day, which raises a real question about how much protection it's actually providing. The disagreement is about whether the device is worth fixing or worth setting aside.
F.O., a 56-year-old man, was three weeks away from walking his daughter down the aisle when his heart attack happened, and the wedding has since been pushed back while he recovers. He is overweight with a sedentary desk job, and his father had bypass surgery at 60 — risk factors that were always there but never quite added up to a diagnosis until now. He had an anterior STEMI treated with PCI three weeks ago, left with a reduced ejection fraction of 28%, and was discharged with a wearable cardioverter-defibrillator vest given his elevated arrhythmic risk in this early post-infarct window, before enough time has passed to know whether a permanent device will even be needed.
At today's follow-up he admits, a little sheepishly, that he's only wearing the vest about half the day — the skin under the electrodes gets irritated, and he can't get comfortable enough in it to sleep, so he's been taking it off most nights and often forgetting to put it back on right away the next morning. A wearable defibrillator only protects a patient while it's actually on his body, and a device worn roughly half the time is providing, at best, roughly half the coverage the discharge plan assumed — a limitation that also runs through the one randomized trial of the vest in this population, which did not show a reduction in arrhythmic death and where wear time was itself the central confounder. His reassessment point is day forty after the infarct, the window that governs when an infarct is treated with primary angioplasty rather than bypass, which puts it a little over two weeks away. He is otherwise recovering as expected from the PCI itself, back to short walks around his neighborhood most afternoons, which makes the vest the one part of his recovery plan that clearly isn't going the way anyone intended. That gap is what the team now has to actually decide what to do about.
Half a day of coverage
I want to fix the fit before we give up on the vest. Skin irritation and sleep discomfort are common, genuinely solvable complaints — a refit, different electrode gel, or an adjusted strap configuration resolves a lot of these cases. The early post-infarct window carries real, documented arrhythmic risk, and I don't want to abandon the bridge strategy because the first fit wasn't comfortable rather than because the strategy itself is wrong for him.
I'd question how much protection a device worn half the time is actually providing before we spend real effort troubleshooting it. If refitting doesn't meaningfully change his wear time, we're continuing to rely on a device that's covering roughly half his day while telling ourselves it's covering all of it. I'd rather put that effort into aggressive early medication titration and close outpatient follow-up — a meaningful share of patients recover ejection fraction above threshold well before the day-forty reassessment, and that's protection that doesn't depend on him remembering to put a vest back on.
I'm not saying medication replaces the vest's actual function if he needs it — I'm saying a device this poorly tolerated may need a real adherence checkpoint before we keep treating it as the primary safety net.
This doesn't have to be either-or. Guideline-directed medical therapy gets maximized starting today regardless of what happens with the vest — that was always going to be true, and it shouldn't have been waiting on this adherence conversation to begin. And to be explicit, because a heart failure regimen this size tends to swallow everything around it: his aspirin, his ticagrelor, and his high-intensity statin all continue untouched. He is three weeks out from a drug-eluting stent, and interrupting dual antiplatelet therapy now is the single fastest way to turn a recovering patient into an emergency. One sequencing point on the ARNI — he goes home from the infarct on an ACE inhibitor, and that has to be stopped a full thirty-six hours before the first dose of sacubitril-valsartan. Overlap is an angioedema risk the label prohibits. Separately, I'd give the refit one genuine attempt, with a specific two-week check-in on actual wear time, timed so it lands just before his day-forty reassessment rather than after it. If he's still under a reasonable wear-time threshold at that point, the plan shifts to closer clinical monitoring and an earlier repeat echocardiogram rather than continuing to lean on a device he isn't, in practice, actually wearing.
Quadruple guideline-directed medical therapy started and uptitrated immediately, independent of the vest question, with sacubitril-valsartan held until his ACE inhibitor had been stopped a full 36 hours. Dual antiplatelet therapy and high-intensity statin continued unchanged. One genuine refit attempt made for the wearable defibrillator, with a specific two-week wear-time check-in scheduled rather than an assumed improvement, timed to fall just before his day-forty reassessment. If wear time remains inadequate at that visit, the plan shifts to closer clinical monitoring and an earlier repeat echocardiogram rather than continued reliance on a device he isn't consistently wearing.