Measuring patient acceptance of implantable cardiac device therapy: initial psychometric investigation of the Florida Patient Acceptance Survey

Depressive coping is a predictor for emotional distress and poor quality of life in a German-Austrian sample of cardioverter-defibrillator implant recipients at 3 months and 1 year after implantation

OBJECTIVE

The implantable cardioverter defibrillator (ICD) has been proven to prolong the lives of patients with life-threatening ventricular arrhythmia. However, implant recipients must cope with numerous challenges. We studied the effects of specific coping strategies and the adaptability of coping in ICD implant recipients.

METHOD

This prospective study investigated the subjective well-being and objective disease course in 180 patients with life-threatening cardiac arrhythmias, who were recruited while awaiting implantation of a cardioverter defibrillator. Patients completed well-validated self-assessment questionnaires before implantation (T0), as well as 3 months (T1) and 1 year (T2) after implantation. In addition, cardiological findings were documented.

RESULTS

Depressive coping (range Beta, -0.36 to -0.58) was found to be a stable highly-significant predictor for low emotional well-being and quality of life. Active problem-oriented coping showed small positive influence (range Beta, 0.10 to 0.19). Employing a broad range of coping strategies was predictive of less emotional distress and better quality of life.

CONCLUSIONS

Depressive coping is a risk factor for emotional distress and poor quality of life after ICD implantation. Patients with this tendency should be identified early and offered supportive psychotherapy.

The ICD shock and stress management program: a randomized trial of psychosocial treatment to optimize quality of life in ICD patients

BACKGROUND

Implantable cardioverter defibrillator (ICD) patients potentially face significant psychological distress because of their risk for life-threatening arrhythmias and the occurrence of ICD shock.

METHODS

The purpose of this study was to test an ICD stress and shock management program delivered in either a six-week format or a one-day workshop format. This intervention was aimed at reducing psychological (anxiety) and physiological (salivary cortisol) markers of distress in ICD patients. Secondary endpoints included measures of quality of life (QOL) and patient acceptance of device therapy, as well as biological mediators of inflammation (TNFalpha and IL-6).

RESULTS

The ICD stress and shock management program resulted in the reduction of anxiety (P < 0.05) and cortisol levels (P < 0.05) in both the six weekly sessions format and the one-day workshop. Measures of anxiety decreased more rapidly with weekly intervention (P = 0.05). Both formats also resulted in a significant increase in patient acceptance of the ICD (P < 0.01). Follow-up assessment from posttreatment (T2) to four-month follow-up (T4) indicated no significant change in depression scores from posttreatment for all groups taken together, but there was a significant group by time effect, such that the workshop group displayed an increase in depression scores from T2 (M = 8.71, SD = 4.39) to T4 (M = 13.57, SD = 11.90), P < 0.05.

CONCLUSIONS

These results suggest that structured interventions for shocked ICD patients involving ICD education and cognitive-behavioral strategies can reduce psychological distress and improve quality of life, regardless of format.

Patient Evaluation of ICD Recall Communication Strategies:A Vignette Study

INTRODUCTION

Communication about the unprecedented number of implantable cardioverter defibrillator (ICD) recalls has proved challenging. While initial studies have explored the psychological impact of recalls on patients, the optimal way to communicate recalls is not currently known. This study investigated the way communication of a recall can affect patients' responses.

METHODS

Sixty-six ICD patients read one of six vignettes that detailed a hypothetical device recall. Vignette variables included the source of recall dissemination (physician vs. media vs. device manufacturer) and the personal relevance (own brand is recalled vs. different brand is recalled). Subsequently, patients rated their agreement to 12 statements concerning their response to the recall on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree).

RESULTS

Patients were significantly more confident in the accuracy of recall information from both their physician and their manufacturer compared with the media, F (2, 63) = 36.10, P < 0.01, eta(2)= 0.53. Interestingly, patients were concerned about the recall regardless of whether their brand of ICD was recalled. Survey results indicated that 78.6% of patients reported learning about recalls from the media. In stark contrast, 77.0% of patients asserted preferring to learn about recalls from their physician.

CONCLUSIONS

ICD patients report increased confidence in the accuracy of the recall information from physicians and manufacturers compared with the media in reporting recalls. Because it seems that most ICD patients learn about recalls from the media, these results demonstrate a disconnect between the initial source of recall information and the patients' desired sources.

Supraventricular Dysrhythmias

Cardiovascular nursing practice includes accountability for the clinical and organizational processes to ensure positive outcomes for patients having cardiac dysrhythmias. For patients with supraventricular dysrhythmias, nurses have studied patient outcomes related to mortality, morbidity, quality of life, psychological and physical functioning, and symptoms. Nurses have also explored these same outcomes associated with the management of supraventricular dysrhythmias. In addition, nurses have contributed to understanding organizational outcomes such as healthcare utilization and costs associated with these patients. For patients with atrial fibrillation after cardiac surgery, nurses have studied patient and organizational outcomes related to mortality, morbidity, symptoms, psychological and physical functioning, and economic outcomes. This research has included numerous interdisciplinary studies, and most of it has been descriptive or observational in design. Areas for future nursing outcomes research, including more interventional studies, are discussed.

Examination of research trends on patient factors in patients with implantable cardioverter defibrillators

BACKGROUND

The implantable cardioverter defibrillator (ICD) is the most effective treatment available for terminating potentially life-threatening ventricular tachycardia and ventricular fibrillation and reducing the risk of mortality. Despite its established health benefits, ICD therapy is accompanied by a unique array of patient and psychological factors meriting ample research attention. The purpose of this paper is to examine research trends and results regarding patient factors in cardiac and ICD research and to discuss key areas for future research.

HYPOTHESIS

: An increase in articles associated with patient factors in cardiac and ICD research will be shown over time.

METHODS

: The Medical Subject Heading (MeSH) system in PubMed was used to index articles under a range of psychosocial headings for both cardiovascular disease and ICDs to quantify the frequency of articles published across time, the journals most frequently utilized, the most productive institutions, and the most common areas of inquiry.

RESULTS

: A significant positive relationship was revealed between patient factors in cardiac research (r=0.96, p<0.01) and ICD research (r=0.88, p<0.01) over time. Research is limited by the small number of investigations and institutions. Of the 178 articles on patient factors in ICD research, the most frequent areas of inquiry were psychosocial treatment (70.79%), anxiety (33.15%), quality of life (32.02%), and depression (29.78%).

CONCLUSION

: Future research examining positive adjustment is warranted, especially in light of increased prophylactic ICD implantation and possible decreased treatment burden associated with decreased shocks.

Quality of Life Among Implantable Cardioverter-Defibrillator Recipients in the Primary Prevention Therapeutic Era

BACKGROUND

Although patients receiving implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden cardiac death are the fastest growing segment of the ICD recipient population, the quality-of-life (QOL) effects of the ICD among primary prevention patients are not well understood. The purpose of this study was to measure and compare the health-related QOL among primary and secondary prevention ICD recipients, and to determine predictive factors for high or low QOL in each group.

METHODS

Forty-five primary prevention and 75 secondary prevention ICD recipients receiving routine care in electrophysiology clinics within the University of Pennsylvania Health System were assessed using several well-validated general and ICD-specific QOL instruments.

RESULTS

Between primary and secondary prevention patients, there were no significant differences in EuroQol 5D (medians: 0.84 vs 0.84, P = 0.71), Health Utilities Index (medians: 0.88 vs 0.85, P = 0.95), Short Form-12 aggregate physical summary (means: 45 vs 46, P = 0.64), and Short Form-12 aggregate mental summary (means: 46 vs 47, P = 0.93) scores. Both primary and secondary prevention patients viewed their devices favorably according to the Florida Patient Acceptance Survey scale, with no significant differences between group means (80 vs 83, P = 0.71). However, substantial fractions of both primary and secondary prevention recipients had particular concerns about lifting (40%), sexual activity (19%), and driving (14%).

CONCLUSIONS

QOL does not significantly differ between primary prevention and secondary prevention ICD recipients. Device recipients had comparable QOL to published, nationwide QOL estimates among non-ICD patients of similar age. The ICD was highly acceptable to most primary and secondary prevention patients.

Psychosocial Issues for Patients with Ventricular Assist Devices: A Qualitative Pilot Study

• Background Surgical implantation of a ventricular assist device is being used increasingly in patients in the United Kingdom, yet few studies have focused on patients’ experiences from a phenomenological (psychological) perspective.

• Objective To explore, through a pilot study, the impact of implantation of a ventricular assist device on patients’ bodies and lives.

• Methods This qualitative retrospective study included 6 patients (4 men and 2 women) and 3 of these patients’ relatives. Patients were from 17 to 50 years old and had used Thoratec, Heartmate, or VentrAssist devices.

• Results The participants’ accounts clustered around a number of themes, 2 of which are reported here: (1) body and self and (2) trust. Each theme comprised several subthemes: body and self had sub-themes of shock, restrictions, scarring, and infection; trust had subthemes of keeping me alive, device failure, and confidence.

• Conclusions The ventricular assist device has a considerable effect on a patient’s body and sense of self. This effect is often accommodated without much difficulty, but some patients and their families need additional psychological support during and after use of a ventricular assist device. Assessment before implantation of such a device can sometimes reveal this need, but such assessment may not be possible in emergency procedures. Trusting the new heart or the native recovered heart may be difficult for some patients. Further research is needed to understand this phenomenon.

Improving SVT Discrimination in Single-Chamber ICDs: A New Electrogram Morphology-Based Algorithm

INTRODUCTION

Wide-spread adoption of ICD therapy has focused efforts on improving the quality of life for patients by reducing "inappropriate" shock therapies. To this end, distinguishing supraventricular tachycardia from ventricular tachycardia remains a major challenge for ICDs. More sophisticated discrimination algorithms based on ventricular electrogram morphology have been made practicable by the increased computational ability of modern ICDs.

METHODS AND RESULTS

We report results from a large prospective study (1,122 pts) of a new ventricular electrogram morphology tachycardia discrimination algorithm (Wavelet Dynamic Discrimination, Medtronic, Minneapolis, MN, USA) operating at minimal algorithm setting (RV coil-can electrogram, match threshold of 70%). This is a nonrandomized cohort study of ICD patients using the morphology discrimination of the Wavelet algorithm to distinguish SVT and VT/VF. The Wavelet criterion was required ON in all patients and all other supraventricular tachycardia discriminators were required to be OFF. Spontaneous episodes (N = 2,235) eligible for ICD therapy were adjudicated for detection algorithm performance. The generalized estimating equations method was used to remove bias introduced when an individual patient contributes multiple episodes. Inappropriate therapies for supraventricular tachycardia were reduced by 78% (90% CI: 72.8-82.9%) for episodes within the range of rates where Wavelet was programmed to discriminate. Sensitivity for sustained ventricular tachycardia was 98.6% (90% CI: 97-99.3%) without the use of high-rate time out.

CONCLUSIONS

Results from this prospective study of the Wavelet electrogram morphology discrimination algorithm operating as the sole discriminator in the ON mode demonstrate that inappropriate therapy for supraventricular tachycardia in a single-chamber ICD can be dramatically reduced compared to rate detection alone.

Costs and quality-of-life effects of implantable cardioverter-defibrillators

Although the clinical efficacy of implantable cardioverter-defibrillators (ICDs) has been convincingly demonstrated in clinical trials, the impact of ICDs on health care costs and recipients' quality of life (QOL) is less certain. The existing medical research on the health care costs and QOL effects of ICDs was reviewed and summarized. Medline and the Institute for Scientific Information's Web of Knowledge were searched for publications reporting costs of care and QOL assessments of ICD recipients. Unpublished and non-peer-reviewed "gray" publications were excluded. Reports were included if they reported primary, original patient data that were collected after 1993, when nonthoracotomy defibrillators entered clinical practice. Two reviewers independently evaluated publications for relevance and quality, abstracted study data, and summarized the findings. Excessive heterogeneity among studies prevented formal meta-analysis, so a narrative synthesis was performed, and key themes were identified from the published research. There were limited published data on the costs of ICD care, especially for the primary prevention of sudden cardiac death. The published research on ICD QOL lacked large, multicenter, longitudinal studies. Many ICD QOL studies were performed in small numbers of patients at single centers. Initial ICD implantation costs ranged (in 2006 United States dollars) from $28,500 to $55,200, with annual follow-up costs ranging from $4,800 to $17,000. QOL was higher for ICD recipients than for patients treated with antiarrhythmic drugs, but there was a substantial prevalence of anxiety, depression, and "loss of control" in ICD recipients, particularly in those who had received ICD shocks. In conclusion, ICD implantation remains costly but may be becoming less expensive over time, and ICD recipients' QOL is significantly affected by their devices.

Managing Congestive Heart Failure Patient Factors in the Device Era

Device-based care such as implantable cardioverter-defibrillators and cardiac resynchronization therapy extends congestive heart failure (CHF) care into a new era. The purpose of this paper is 2-fold: (1) to review the development of device-based CHF management and the implications from a medical and patient management perspective, and (2) to provide assessment and treatment approaches on how to clinically manage patient outcomes optimally. Quality of life, depression, and anxiety are targeted as concerns for patients with CHF and cardiac resynchronization therapy/implantable cardioverter-defibrillators. Brief clinic-based interview questions and formal assessment tools are reviewed. Furthermore, a cognitive-behavioral paradigm using the "Appropriate Education, Behavioral Support, and Cognitive Coping" (ABC) model is proposed to aid health care professionals in addressing patients' device-specific concerns. Available research suggests the need for future studies assessing the efficacy of cognitive-behavioral treatments in patients with CHF and cardiac resynchronization therapy/implantable cardioverter-defibrillators.

The use of unipolar intracardiac impedance for discrimination of haemodynamically stable and unstable arrhythmias in man

AIMS

To determine the feasibility of discriminating haemodynamically stable from unstable arrhythmias using right ventricular (RV) unipolar intracardiac impedance (Z).

METHODS AND RESULTS

A quadrapolar temporary pacing electrode was positioned at the RV apex and unipolar impedance was measured between the tip electrode and a surface patch electrode. Changes in peak-to-peak Z amplitude were measured simultaneously with surface ECG and blood pressure during induced arrhythmias. Haemodynamic instability was defined as a systolic pressure of <90 mmHg. There were 25 episodes of ventricular fibrillation (VF) induced in 15 patients, 18 episodes of ventricular tachycardia in 16 patients, and 33 episodes of supraventricular tachycardia (SVT) in 16 patients. Compared with the baseline rhythm, mean Z amplitude reduced from 51.3+/-7.7 to 11.2+/-7.4 Ohm (P<0.001) during VF, from 52.2+/-6.3 to 21.7+/-10.1 Ohm (P<0.01) during haemodynamically unstable VT, from 55.0+/-6.9 to 39.9+/-11 Ohm (ns) during stable VT, and from 56.4+/-8.4 to 36.9+/-9.3 Ohm during SVT (P<0.001).

CONCLUSION

Right ventricular unipolar impedance is an adequate sensor for determining mechanical ventricular contraction and acts as a surrogate marker for a fall in arterial blood pressure during VF. However, for ventricular and supraventricular tachycardias, variations between patients did not allow adequate discrimination between stable and unstable arrhythmias.

Device Implant Technique and Consideration of Body Image: Specific Procedures for Implantable Cardioverter Defibrillators in Female Patients

OBJECTIVES

The purpose of this paper is to describe the psychological effects of implantable cardioverter defibrillator (ICD) implantation in female patients and to make clinical recommendations for providers to optimize health outcomes for women.

BACKGROUND

Traditional ICD implantation produces visible scarring. Changes in physical appearance affect body image in all ICD recipients but may be more onerous in female ICD recipients. Electrophysiologists have described cosmetic approaches to device placement that appear promising and may warrant consideration in female patients.

CONCLUSIONS

Active discussion and consideration of alternative device implant techniques are indicated in female patients. Female patients should also be given time to make preoperative decisions, and family members should be engaged in decision making. The investigation of cosmetic implants is noteworthy and could improve quality of life, adjustment, and psychological fitness of female ICD recipients.

Psychological aspects of cardiac devices and recalls in patients with implantable cardioverter defibrillators

The product recall of an implantable cardioverter defibrillator (ICD) creates a potentially stressful event for patients. This study briefly describes the psychological adjustment of patients with implantable devices and makes recommendations for the management of device recalls and adverse outcomes to minimize psychological distress. Because the occurrence of ICD-specific fears and symptoms of anxiety are the most common psychological symptoms experienced by ICD recipients, a comprehensive care plan to attend to recall procedures and patient distress is needed. It is suggested that recalls do not affect all ICD patients equally, with risk factors for poor psychological adjustment to ICDs including younger age (< 50 years), shock experience, and female gender that may be associated with increased recall anxiety. Specific recommendations for device recall management include formalizing clinic responses to recall before and after implantation and innovative uses of patient support systems to communicate recall responses.