Anxiety and Depression in Implanted Cardioverter-Defibrillator Recipients and Heart Failure: A Review

Fear of COVID-19 Predicts Depression, Anxiety and Post-Traumatic Stress Disorders in Patients with Implantable Cardioverter Defibrillators and Is Mediated by Positive and Negative Affects-A Cross-Sectional Study

The COVID-19 pandemic affected both the physical and mental health of the general population. People with cardiac diseases seem to be particularly vulnerable to the implications of the pandemic. However, studies on the mental health impact of the COVID-19 pandemic on people with implantable cardioverter defibrillator (ICDs) are lacking. Thus, we aimed to explore the level of fear of COVID-19 and the prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) in ICD patients. Furthermore, we aimed to identify novel predictors for anxiety, depression and PTSD, including COVID-19-related variables, and to assess whether positive affects (PAs) and negative affects (NAs) mediate the relationship between the level of fear of COVID-19 and anxiety, depression and PTSD, respectively. The data of 363 patients with ICDS who had been prospectively included in this study between 2020 and 2023, were analyzed. Potential predictors for anxiety, depression, and PTSD were identified using logistic regression. To identify indirect mediating effects of PAs and NAs, we applied the PROCESS regression path analysis modeling tool. The prevalence of anxiety was 9.19%, of depression 10.85%, and of PTSD 12.99%. Being unemployed was the strongest predictor for anxiety (OR = 10.39) and depression (OR = 6.54). Younger age predicted anxiety (OR = 0.95) and PTSD (OR = 0.92). Receiving low social support was associated with anxiety (OR = 0.91), depression (OR = 0.88) and PTSD (OR = 0.91). Patients with a history of COVID-19 (OR = 3.58) and those who did not feel well-informed about COVID-19 (OR = 0.29) were more likely to be depressed. Higher levels of fear of COVID-19 predicted anxiety (OR = 1.10), depression (OR = 1.12) and PTSD (OR = 1.14). The relationship between fear of COVID-19 and anxiety or depression was fully mediated by PAs and NAs, while NAs partially mediated the relationship between fear of COVID-19 and PTSD. Vulnerable subgroups of ICD patients may need additional psychological and educational interventions due to fear of COVID-19, anxiety, depression and PTSD during the pandemic.

Patient-Reported Quality of Life, Depression, Anxiety, and Physical Activity in Patients Receiving an Implantable Cardioverter-Defibrillator for Primary versus Secondary Prevention: A Single-Centre, Prospective, Observational Cohort Study

STUDY OBJECTIVES

The aim of the study was to evaluate of the quality of life, depression, anxiety levels, and physical activity in the groups after the implantation of an ICD or CRT-D.

METHODS

All subjects (111 CHF patients) underwent tests to assess the quality of life (NHP), the level of physical activity (IPAQ), the level of perceived stress (PSS), and the incidence of depression (BDI).

RESULTS

After the implantation, physical activity (PA) of the patients from the primary prevention (PP) group remains unchanged, whereas in the secondary prevention (SP) group, it decreases noticeably. Physical activity is lower in the SP group in comparison with the PP group. There are no statistically significant differences in the level of depression. The scores in the second part of the NHP questionnaire indicate that the SP group significantly more often declare problems with housework and with social life than the PP group.

CONCLUSIONS

1. The type of prevention does not have an influence on the level of anxiety, stress, or depression. 2. The patients after implantation as SP are physically less active; lower PA is associated additionally with the higher NYHA class and chronic kidney disease. 3. The quality of life of the patients from SP group is at a lower level than patients from PP group.

Efficacy of digital health interventions on depression and anxiety in patients with cardiac disease: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2022;3:445-454. [PMID: 36712158 PMCID: PMC9707908 DOI: 10.1093/ehjdh/ztac037]

Aims

Depression and anxiety have a detrimental effect on the health outcomes of patients with heart disease. Digital health interventions (DHIs) could offer a solution to treat depression and anxiety in patients with heart disease, but evidence of its efficacy remains scarce. This review summarizes the latest data about the impact of DHIs on depression/anxiety in patients with cardiac disease.

Methods and results

Articles from 2000 to 2021 in English were searched through electronic databases (PubMed, Cochrane Library, and Embase). Articles were included if they incorporated a randomized controlled trial design for patients with cardiac disease and used DHIs in which depression or anxiety was set as outcomes. A systematic review and meta-analysis were performed. A total of 1675 articles were included and the screening identified a total of 17 articles. Results indicated that telemonitoring systems have a beneficial effect on depression [standardized mean difference for depression questionnaire score -0.78 (P = 0.07), -0.55 (P < 0.001), for with and without involving a psychological intervention, respectively]. Results on PC or cell phone-based psychosocial education and training have also a beneficial influence on depression [standardized mean difference for depression questionnaire score -0.49 (P = 0.009)].

Conclusion

Telemonitoring systems for heart failure and PC/cell phone-based psychosocial education and training for patients with heart failure or coronary heart disease had a beneficial effect especially on depression. Regarding telemonitoring for heart failure, this effect was reached even without incorporating a specific psychological intervention. These results illustrate the future potential of DHIs for mental health in cardiology.

Delivering an efficient and effective support group for patients with implantable cardioverter-defibrillators (ICDs): patient perspectives of key concerns and predictors of inclination to attend

BACKGROUND

A subset of patients experience psychological distress following insertion of an implantable cardioverter-defibrillator (ICD) and ICD support groups are recommended, however access to these groups is limited. This study aimed: to gauge a better understanding of patients' key ICD-related concerns; to determine patient interest in a support group and topics deemed helpful to address in a support group; and to examine factors which affect patient inclination to attend.

METHODS

One hundred and thirty nine patients completed the ICD Patient Concerns Questionnaire - Brief (ICDC-B) and a semi-structured survey. Non-parametric tests were used to examine associations and differences in the quantitative data. Qualitative data were analysed using thematic analysis.

RESULTS

42% of respondents said they would attend a support group and inclination to attend was associated with higher ICD concerns and a shorter time since implant. Topics considered important to address in a group were information about heart conditions and devices, the impact of an ICD on daily life and coping with fear of shocks.

CONCLUSION

We concluded that there is interest in further support amongst many patients and that ICD support groups may be delivered efficiently by targeting patients who have higher levels of ICD concerns and within the first few years after implant.

Nocturnal phantom shock cessation with zolpidem

A 77 year old man with a biventricular ICD-pacemaker complained of painful, electric jolts disturbing him nightly from sleep. Extensive work-up including device interrogation revealed no defibrillations or arrhythmia, and he was subsequently diagnosed with phantom shocks (PS). His nightly PS symptoms terminated after starting zolpidem 10 mg each night. To date, literature review reveals fifteen articles reporting 163 phantom shock (PS) cases. PS affects 5-9% of ICD recipients. Risk factors include psychiatric disease, atrial fibrillation, NYHA functional status III or greater, prior shock storm, and intraoperative awareness during ICD placement, with defibrillation threshold testing. This report describes a successful PS intervention, and reviews the current knowledge available in the pathophysiology and treatment of PS.

Factors associated with anxiety and depression among patients with implantable cardioverter defibrillator

AIMS AND OBJECTIVES

To identify factors associated with anxiety and depression of patients with implantable cardioverter defibrillators.

BACKGROUND

Implantable cardioverter defibrillator is effective to increase survival from life-threatening arrhythmias, but it lowers health-related quality of life. Anxiety and depression had significant negative association with health-related quality of life. However, knowledge about factors associated with these two negative emotions in this specific population is inadequate.

DESIGN

A cross-sectional descriptive design was conducted. Secondary analysis was performed to address the aim.

METHODS

A convenience sampling of patients with implantable cardioverter defibrillators was performed. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale through face-to-face interview.

RESULTS

Stepwise multivariable regression results showed that older age (aged 60-69 and ≥70: B = 2·08 and 3·31, p = 0·039 and <0·001), self-care dependence (B = 3·47, p < 0·001), being married (B = -2·21, p = 0·004) and having ischaemic heart disease (B = -1·80, p = 0·008) were significantly associated with depression. However, there was no significant factor associated with anxiety.

CONCLUSIONS

Factors associated with depression among patients with implantable cardioverter defibrillator are identified. Older age (aged ≥60) and more self-care dependence have positive, but being married and having ischaemic heart disease have negative association with depression. Strategies to reduce psychological distress are highlighted.

RELEVANCE TO CLINICAL PRACTICE

The study findings direct the care to improve health-related quality of life by reducing and controlling vulnerabilities arising from depression. Patients who are older people (≥aged 60) and more self-care dependent perceive higher depression. Nursing strategies are suggested to reduce depression especially for those who are older people and more self-care dependent. Early screening is essential to provide immediate care for reducing vulnerabilities arising from depression. Performing comprehensive assessment for self-care ability and providing adequate assistance are crucial. Family involvement may reduce depression through providing physical and psychosocial support.

The Challenges of Living With an Implantable Cardioverter Defibrillator: A Qualitative Study

BACKGROUND

Dysrhythmia is one of the most common causes of sudden cardiac death worldwide. An implantable cardioverter defibrillator is the most effective method of treatment for dysrhythmias causing cardiac arrest. However, living with an implantable cardioverter defibrillator is associated with challenges such as fear, anxiety, and depression.

OBJECTIVES

The purpose of this study was to identify the challenges of living with an implantable cardioverter defibrillator.

PATIENTS AND METHODS

In this qualitative study, an interpretive phenomenological approach was used, with thirteen participants (seven men and six women) between the ages of 21 and 70 years old (mean = 58.15, SD = 14.4). The duration of having an implantable cardioverter defibrillator was 1 - 120 months (mean = 23.15, SD = 33.31). Maximum variation sampling was used to purposefully select the participants from the governmental Imam Khomeini hospital in Tehran, Iran, between May and October of 2013. Semi-structured interviews were conducted for 30 to 45 minutes, and Van Manen's six-step method was used in this study.

RESULTS

The challenges of living with an implantable cardioverter defibrillator include: living with fear, concerns about the future, concerns about device malfunction, fearing death during the shock, pain due to the shock, loss of control, the cost of the device, and the lifestyle limitations.

CONCLUSIONS

Patients who live with implantable cardioverter defibrillators face many concerns and challenges. Therefore, the role of nurses in teaching patients before and after implementation is very important.

Concerns about implantable cardioverter-defibrillator shocks mediate the relationship between actual shocks and psychological distress

AIMS

Although most implantable cardioverter-defibrillator (ICD) patients cope well, fears about receiving ICD shocks have been identified as a major determinant of psychological distress. The relationships among ICD-related concerns, receipt of defibrillating shocks, and symptoms of anxiety and depression have not yet been investigated. Our objective was to examine whether the relationship between receipt of defibrillating shocks and psychological distress was mediated by patients' concerns related to their ICD.

METHODS AND RESULTS

All Swedish ICD-recipients were invited to this cross-sectional correlational study; 3067 completing the survey (55% response rate). Their mean age was 66 ± 11 years, and 80% were male. One-third (35%) had received defibrillating shocks, and 26% had high ICD-related concerns. Regression analyses demonstrated that having received at least one shock significantly predicted symptoms of anxiety and depression [odds ratio (OR) 1.58 and OR 3.04, respectively]. The association between receipt of shocks and psychologically distress was mediated by high ICD-related concerns which explained 68% of the relationship between shocks and symptoms of anxiety, and 54% of the relationship between shocks and symptoms of depression.

CONCLUSION

Implantable cardioverter-defibrillator-related concerns have a bigger impact on psychological distress than receipt of an actual shock. Assessing ICD-related concerns in clinical practice can identify patients at risk for psychological distress. Further research on assessment of, and interventions targeting, ICD-related concerns is warranted.

A pilot study of a mindfulness based stress reduction program in adolescents with implantable cardioverter defibrillators or pacemakers

Adolescents with implantable cardioverter defibrillators (ICDs) or pacemakers (PMs) face unique challenges that can cause psychosocial distress. Psychosocial interventions are effective for adults with cardiac devices and could potentially impact adolescents' adjustment to these devices. Mindfulness Based Stress Reduction (MBSR) is a structured psycho-educational program that includes meditation, yoga, and group support and has been studied extensively among adults. This study examined the feasibility of the MBSR program for adolescents with ICDs/PMs, a population previously unexamined in the research literature. The participants completed measures of anxiety and depression (Hospital Anxiety and Depression Scale) and coping (Responses to Stress Questionnaire) at baseline and after the six-session MBSR intervention. Mean age of the cohort (n = 10) was 15 ± 3 years, 6 were male, 6 had a PM, and 4 had an ICD. Feasibility was demonstrated by successful recruitment of 10 participants, 100 % participation and completion. Anxiety decreased significantly following the intervention, with a large effect size, t[9] = 3.67, p < .01, ŋ (2) = .59. Anxiety frequency decreased from baseline to post-intervention (Fisher's exact test p = .024), and 90 % of participants reported decreased anxiety scores post-intervention. Coping skills related negatively to anxiety (r = -.65, p = .04) and depression (r = -.88, p = .001). Post-intervention, the group independently formed their own Facebook group and requested to continue meeting monthly. Although generalizability is limited due to the small sample size, this successful pilot study paves the way for larger studies to examine the efficacy of MBSR interventions in adolescents with high-risk cardiac diagnoses.

Incidence of defibrillator shocks after elective generator exchange following uneventful first battery life

Background

A significant number of implantable cardioverter‐defibrillator (ICD) patients do not experience shocks after ICD implant. Elective generator exchange (GE) has been associated with increased risk of infection and ICD lead failure. There is a paucity of contemporary data reporting on shock incidence with replacement devices.

Methods and Results

Patients undergoing elective GE (n=24 203) who transmit data remotely via a remote monitoring system were analyzed to determine the incidence of ICD shocks after GE. A total of 16 230 patients (67%) did not experience a shock with the first ICD (group A), and 7973 (33%) received at least 1 shock (group B). Patients in group A were older (71.3 versus 68.8 years, P<0.001) and more often female (71% versus 77% male, P<0.001). Over an average follow‐up of 1.9±1.2 years after GE, the proportion of patients with shocks and risk of ICD shocks was lower for those who did not receive a shock during the first battery life (group A: 9.9% versus 27.7%, hazard ratio 0.36, 95% CI 0.34 to 0.38, P<0.001). The cumulative rate of ICD shocks at 5 years after GE was 25.7% in group A and 51.1% in group B.

Conclusions

In this large cohort of ICD patients implanted across the United States, two thirds did not receive ICD shock therapy prior to GE. The occurrence of ICD shocks prior to GE is an important predictor of shocks after GE; however, even among those without shocks during first battery life, the incidence of shocks at 5 years following GE is >25%. These data should support informed decision making for patients and physicians at the time of ICD generator end of service.

Patient perspective on remote monitoring of cardiovascular implantable electronic devices: rationale and design of the REMOTE-CIED study

Background

Remote patient monitoring is a safe and effective alternative for the in-clinic follow-up of patients with cardiovascular implantable electronic devices (CIEDs). However, evidence on the patient perspective on remote monitoring is scarce and inconsistent.

Objectives

The primary objective of the REMOTE-CIED study is to evaluate the influence of remote patient monitoring versus in-clinic follow-up on patient-reported outcomes. Secondary objectives are to: 1) identify subgroups of patients who may not be satisfied with remote monitoring; and 2) investigate the cost-effectiveness of remote monitoring.

Methods

The REMOTE-CIED study is an international randomised controlled study that will include 900 consecutive heart failure patients implanted with an implantable cardioverter defibrillator (ICD) compatible with the Boston Scientific LATITUDE® Remote Patient Management system at participating centres in five European countries. Patients will be randomised to remote monitoring or in-clinic follow-up. The In-Clinic group will visit the outpatient clinic every 3–6 months, according to standard practice. The Remote Monitoring group only visits the outpatient clinic at 12 and 24 months post-implantation, other check-ups are performed remotely. Patients are asked to complete questionnaires at five time points during the 2-year follow-up.

Conclusion

The REMOTE-CIED study will provide insight into the patient perspective on remote monitoring in ICD patients, which could help to support patient-centred care in the future.

Characteristics associated with anxiety, depressive symptoms, and quality-of-life in a large cohort of implantable cardioverter defibrillator recipients

OBJECTIVE

Although most patients with implantable cardioverter defibrillators (ICDs) adjust well, some have considerable psychological distress. Factors associated with psychological adjustment in ICD-recipients are still not well understood. Our purpose was to describe quality-of-life (QoL) and prevalence of self-reported symptoms of anxiety and depression in a large national cohort of ICD-recipients, and to determine socio-demographic, clinical, and ICD-related factors associated with these variables.

METHODS

A cross-sectional, correlational design was used. All eligible adult ICD-recipients in the Swedish ICD- and Pacemaker Registry were invited to participate. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS), and QoL with the EuroQol-5D.

RESULTS

A total of 3067 ICD-recipients (66±11years, 80% male) were included. The mean HADS score was 3.84±3.70 for anxiety symptoms and 2.99±3.01 for symptoms of depression. The mean EQ-5D index score was 0.82±0.21. The probability of symptoms of anxiety and depression was associated with younger age, living alone, and a previous history of myocardial infarction or heart failure. Additionally, female ICD-recipients had a higher probability of symptoms of anxiety. A higher level of ICD-related concerns was most prominently related to symptoms of anxiety, depressive symptoms and poorer QoL, while number of shocks, ICD-indication and time since implantation were not independently related.

CONCLUSIONS

In this large cohort of ICD-recipients, the association of ICD-related concerns with symptoms of anxiety, depressive symptoms, and poor QoL suggests that ICD specific factors should be addressed in order to improve outcomes.

Association of anxiety disorders and depression with incident heart failure

OBJECTIVE

Depression has been associated with increased risk of heart failure (HF). Because anxiety is highly comorbid with depression, we sought to establish if anxiety, depression, or their co-occurrence is associated with incident HF.

METHODS

A retrospective cohort (N = 236,079) including Veteran's Administration patients (age, 50-80 years) free of cardiovascular disease (CVD) at baseline was followed up between 2001 and 2007. Cox proportional hazards models were computed to estimate the association between anxiety disorders alone, major depressive disorder (MDD) alone, and the combination of anxiety and MDD, with incident HF before and after adjusting for sociodemographics, CVD risk factors (Type 2 diabetes, hypertension, hyperlipidemia, obesity), nicotine dependence/personal history of tobacco use, substance use disorders (alcohol and illicit drug abuse/dependence), and psychotropic medication.

RESULTS

Compared with unaffected patients, those with anxiety only, MDD only, and both disorders were at increased risk for incident HF in age-adjusted models (hazard ratio [HR] = 1.19 [ 95% confidence interval {CI} = 1.10-1.28], HR = 1.21 [95% CI = 1.13-1.28], and HR = 1.24 [95% CI = 1.17-1.32], respectively). After controlling for psychotropics in a full model, the association between anxiety only, MDD only, and both disorders and incident HF increased (HRs = 1.46, 1.56, and 1.74, respectively).

CONCLUSIONS

Anxiety disorders, MDD, and co-occurring anxiety and MDD are associated with incident HF in this large cohort of Veteran's Administration patients free of CVD at baseline. This risk of HF is greater after accounting for protective effects of psychotropic medications. Prospective studies are needed to clarify the role of depression and anxiety and their pharmacological treatment in the etiology of HF.

Depression, psychological distress, and quality of life in patients with cardioverter defibrillator with or without cardiac resynchronization therapy

Congestive heart failure is frequent and leads to reduced exercise capacity, reduced quality of life (QoL), and depression in many patients. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) offer therapeutic options and may have an impact on QoL and depression. This study was performed to evaluate physical and mental health in patients undergoing ICD or combined CRT/ICD-implantation (CRT-D). Echocardiography, spiroergometry, and psychometric questionnaires [Beck Depression Inventory, General World Health Organization Five Well-being Index (WHO-5), Brief Symptom Inventory and 36-item Short Form (SF-36)] were obtained in 39 patients (ICD: 17, CRT-D: 22) at baseline and 6-month follow-up (FU) after device implantation. CRT-D patients had a higher NYHA class and broader left bundle branch block than ICD patients at baseline. At FU, ejection fraction (EF), peak oxygen uptake, and NYHA class improved significantly in CRT-D patients but remained unchanged in ICD patients. Patients with CRT-D implantation showed higher levels of depressive symptoms, psychological distress, and impairment in QoL at baseline and FU compared to ICD patients. These impairments remained mostly unchanged in all patients after 6 months. Overall, these findings imply that there is a need for careful assessment and treatment of psychological distress and depression in ICD and CRT-D patients in the course of device implantation as psychological burden seems to persist irrespective of physical improvement.

Depression and cardiac disease: epidemiology, mechanisms, and diagnosis

In patients with cardiovascular disease (CVD), depression is common, persistent, and associated with worse health-related quality of life, recurrent cardiac events, and mortality. Both physiological and behavioral factors—including endothelial dysfunction, platelet abnormalities, inflammation, autonomic nervous system dysfunction, and reduced engagement in health-promoting activities—may link depression with adverse cardiac outcomes. Because of the potential impact of depression on quality of life and cardiac outcomes, the American Heart Association has recommended routine depression screening of all cardiac patients with the 2- and 9-item Patient Health Questionnaires. However, despite the availability of these easy-to-use screening tools and effective treatments, depression is underrecognized and undertreated in patients with CVD. In this paper, we review the literature on epidemiology, phenomenology, comorbid conditions, and risk factors for depression in cardiac disease. We outline the associations between depression and cardiac outcomes, as well as the mechanisms that may mediate these links. Finally, we discuss the evidence for and against routine depression screening in patients with CVD and make specific recommendations for when and how to assess for depression in this high-risk population.

Psychiatric comorbidity among terminally ill patients in general practice in the Netherlands: a comparison between patients with cancer and heart failure

BACKGROUND

It is unclear whether psychiatric disorders are specifically related to the terminal phase of cancer, or independent of the underlying disease.

AIM

To investigate the rate of psychiatric comorbidity and psychotropic drugs prescription in terminally ill patients in the GP setting, comparing both patients with terminal cancer and heart failure.

DESIGN AND SETTING

Retrospective cohort study using the Utrecht General Practitioner Research Network.

METHOD

Equally-sized groups of patients with terminal cancer and heart failure were randomly selected from the database of four general practices over the years 2005-2009. Psychiatric comorbidities were determined using the International Classification for Primary Care (ICPC) codes and psychotropic drugs prescriptions using the Anatomical Therapeutic Chemical (ATC) Classification System codes.

RESULTS

A total of 191 terminally ill patients were included in the study (111 with cancer and 80 with heart failure). The mean age for patients with terminal cancer (70.8 years, standard deviation [SD] = 12.8) was 15 years younger than that of patients with heart failure (85.6 years, SD = 9.2). Half of the terminally ill patients (50.3 %) were prescribed psychotropics, but only 13.6% of them had obtained a psychiatric diagnosis. There were no significant differences in prevalence of psychiatric disease and psychotropic drug prescription between patients with terminal cancer and heart failure.

CONCLUSION

The results demonstrate a high use of psychotropic drugs in terminally ill patients, often in the absence of a formal diagnosis of a psychiatric disorder. The absence of differences between patients with cancer and heart failure suggests that psychiatric diagnoses and increased psychotropic prescriptions are primarily related to the terminal stage of the disease and not to the background of cancer or heart failure.