Gender Disparities

Improving the Care for Women With S-ICDs

Results of a new study1 show that women with a subcutaneous implantable cardioverter-defibrillator (S-ICD) experience a variety of issues that have a substantial impact on their daily life.

According to the study authors, most of the physical, esthetical, and situational issues that were identified can be mitigated from adequate counseling and implanter awareness.

Willeke van der Stuijt, MD, a research fellow with the Department of Cardiology at Amsterdam UMC, Universitair Medische Centra in the Netherlands, was one of the study’s coauthors. Consultant360 asked her about the concerns that women have regarding their S-ICD and what you can do to address those concerns.

CONSULTANT360: What was the impetus for your study?

Willeke van der Stuijt: In the outpatient clinic of our tertiary hospital, we heard several negative reports from women with an S-ICD about the position of the S-ICD in relation to their bra. Also, some patients mentioned that they felt insecure because of the visibility of the scars and generator. This is something that was never published about, since most ICD studies have had populations predominantly composed by men. We wanted to evaluate issues of the S-ICD specific to women to see what we could do to improve the care for these patients. 

CON: Can you highlight some of the main issues that women with S-ICD may experience in each of the 3 main categories you identified? And what can cardiologists do to help prevent or alleviate each of these issues?

WvdS: Here are the main issues:

Physical: Many women reported that the postoperative pain after S-ICD implantation exceeded their expectations. From anesthesiology studies, we know that women are at higher risk for developing severe postoperative pain and that they tend to give higher pain scores compared with men. As health care professionals, we should inform patients about postoperative pain to assure them that pain is not uncommon. In our experience, postoperative pain after S-ICD implantation is usually well-managed with oral analgesia. 

Esthetical: The generator of the S-ICD is implanted on the left side of the thoracic wall, near the left breast. This position interferes with almost every bra, and this caused discomfort among a large group of women in our study cohort. Bras also often contain a supportive side boning that lies directly over the generator, which many women consider uncomfortable. When asked, patients preferred a more cranial and posterior position of the generator. We advise implanting physicians to mark the bra position preimplant so that they can try to place the generator more cranially and posteriorly—but only if this does not have a negative impact on the shock vector. 

Situational: A large group in our study cohort expressed an unpleasant feeling during intimate contact with their sexual partner, and many of them stated that they ask their partners to avoid the area around the generator and lead. In some cases, the S-ICD is a daily reminder of their cardiac disease, which makes them feel less attractive. When a patient with a difficult sexual relationship as a result of the cardiac disease or ICD presents, physicians could consider referring her to a sexologist. Moreover, awareness and open communication about nonmedical issues related to the S-ICD will alleviate many of these issues. 

CON: A patient is pregnant and has an S-ICD. What are some points that a cardiologist should bring up in his or her conversations with this patient during pregnancy and after childbirth? Do you think the development of guidelines could help guide these conversations?

WvdS: In our study, respondents expressed a wish for more clarity regarding the planning of their childbirth. To them, it was unclear whether they could give birth in their local hospital or if they needed to be referred to a tertiary center. This emphasizes the importance of local arrangements between the cardiology and obstetrics/gynecology departments. 

Furthermore, it is unclear whether the position of the S-ICD changes during pregnancy or what the complications of childbirth could be when the mother has an S-ICD. More research on this subject is needed to develop international guidelines. Research and guidelines will facilitate the conversation between physicians and patients, reinforce arrangements between departments, and improve the care for pregnant patients with S-ICDs. 

CON: How does age or body mass index affect women’s challenges with S-ICD?

WvdS: In our studied cohort, there was no difference between women aged younger than 50 years and women aged 50 years or older. However, a low body mass index seems to aggravate some issues, such as movement of generator and lead, visibility of the S-ICD, a changed shape of the breast, and negative remarks by bystanders.

CON: How do you think this study reflects the overall gender disparities in cardiology? And how do you hope this study impacts the outlook on and care of this particular gender-specific issue?

WvdS: Although nearly 30% of all patients with an ICD are women2, this patient population is underrepresented in most ICD studies. This extends to other disciplines of cardiology as well. Guidelines almost always suggest similar treatment in men and women, but we lack evidence that supports these recommendations. Although our study involves only a small portion of ICD therapy, we hope that it helps raise awareness about differences between male and female patients and that it serves as a foundation for further research aiming to improve the care for women with S-ICDs. 


  1. van der Stuijt W, Quast AFBE, Baalman SWE, Nordkamp LRAO, Wilde AAM, Knops RE. Improving the care for female subcutaneous ICD patients: A qualitative study of gender-specific issues. Int J Cardiol. 2020;S0167-5273(20)31789-7. doi:10.1016/j.ijcard.2020.05.091
  2. Patel NJ, Edla S, Deshmukh A, et al. Gender, racial, and health insurance differences in the trend of implantable cardioverter-defibrillator (ICD) utilization: a United States experience over the last decade. Clin Cardiol. 2016;39(2):63-71. doi:10.1002/clc.22496