Long-term quality of life and uncertainty in patients living with an implantable cardioverter defibrillator

Protocol for the development and validation of a clinical measurement tool for fear of disease progression and recurrence in cardiac patients

Introduction

One in two cardiac patients fear having another heart event or their heart condition getting worse. Research in other chronic illnesses demonstrates that screening for fear of progression and recurrence is vital for adequately addressing such concerns in clinical care. The current project aims to develop and validate a measure for fear of progression and recurrence in cardiac patients.

Methods

The Fear of Cardiac Recurrence and Progression Scale (FCRP) will be developed through a multistep process. An initial item pool will be generated through a review of the literature and existing measures and consultation with and feedback from key informants. The item pool will be tested in a sample of over 250 adults who have ever had an acute coronary event, undergone cardiac surgery, or a chronic cardiac condition. Exploratory factor analysis will be used to identify the underlying factors, and Rasch analysis will be used to reduce the number of items. A short form version of the FCRP will be developed for use as a brief screening tool, informed by clinical relevance and Rasch psychometric indices.

Discussion

While many cardiac patients experience fears related to the progression or recurrence of their illness, there remains the need for a validated tool with which these concerns can be identified and measured. It is expected that the design and validation of the FCRP will aid identification of cardiac patients suffering from clinically significant levels of fear of progression and recurrence and facilitate the design of tailored psychological interventions to target these fears.

A Prospective Longitudinal Study of Health-Related Quality of Life and Psychological Wellbeing after an Implantable Cardioverter Defibrillator in Patients with Genetic Heart Diseases

Background

Genetic heart diseases (GHDs) can be clinically heterogeneous and pose an increased risk of sudden cardiac death (SCD). The implantable cardioverter-defibrillator (ICD) is a lifesaving therapy. Impacts on prospective and long-term psychological and health-related quality of life (HR-QoL) after ICD implant in patients with GHDs are unknown.

Objectives

Investigate the psychological functioning and HR-QoL over time in patients with GHDs who receive an ICD, and identify risk factors for poor psychological functioning and HR-QoL.

Methods

A longitudinal, prospective study design was used. Patients attending a specialized clinic, diagnosed with a GHD for which they received an ICD between May 2012 and January 2015, were eligible. Baseline surveys were completed prior to ICD implantation with 5-year follow-up after ICD implant. We measured psychological functioning (Hospital Anxiety Depression Scale, Florida Shock Anxiety Scale), HR-QoL (Short-Form 36v2), and device acceptance (Florida Patient Acceptance Scale).

Results

Forty patients were included (mean age 46.3 ± 14.2 years; 65.0% male). Mean psychological and HR-QoL measures were within normative ranges during follow-up. After 12 months, 33.3% and 19.4% of participants showed clinically elevated levels of anxiety and depression, respectively. Longitudinal mixed-effect analysis showed significant improvements from baseline to first follow-up for the overall cohort, with variability increasing after 36 months. Nontertiary education and female sex predicted worse mental HR-QoL and anxiety over time, while comorbidities predicted depression and worse physical HR-QoL.

Conclusion

While the majority of patients with a GHD adjust well to their ICD implant, a subset of patients experience poor psychological and HR-QoL outcomes.

Quality of Life in patients with nonalcoholic fatty liver disease: Structure and related factors focusing on illness uncertainty

AIM

Patients with nonalcoholic fatty liver disease (NAFLD) have a low quality of life (QOL) and illness uncertainty. This study examined the structure of QOL and associated factors, including illness uncertainty, among individuals with NAFLD.

METHODS

A cross-sectional survey was conducted using a self-administered questionnaire for outpatients with NAFLD. QOL was measured using the Short Form-8. Dietary habits, physical activity level, illness uncertainty, health locus of control, and knowledge of NAFLD were assessed. Path analysis was used to study the associated factors of QOL and their structure, including uncertainty of disease.

RESULTS

Path analysis of 168 NAFLD patients indicated that a high Physical Component Summary score on the Short Form-8-representing physical QOL-was predicted by a body mass index <25 kg/m2 and high educational level. A high Mental Component Summary score-representing mental QOL-was predicted by being male, good dietary habits, low illness uncertainty, and presence of consultants. The model showed satisfactory goodness-of-fit without being rejected by the chi-square test (goodness-of-fit index = .947, adjusted goodness-of-fit index = .917, comparative fit index = .967, root mean square error of approximation = 0.023).

CONCLUSIONS

Nurses need to work closely with NAFLD patients as consultants, providing adequate information about the causes, treatments, and dietary habits, and focusing on the individual's perception of health. This could reduce illness uncertainty and contribute to the improvement of QOL.

Uncertainty and depressive symptoms as mediators of quality of life in patients with heart failure

Uncertainty in illness is regarded as a source of stress in many chronic diseases and is negatively related to health-related quality of life (HRQoL). However, studies on the relationship between uncertainty and HRQoL in patients with heart failure are limited. This study used Mishel's theory of uncertainty in illness to investigate the mediating role of uncertainty in illness and depressive symptoms between symptom distress and HRQoL in patients with heart failure. This study used a cross-sectional correlation design. Participants were recruited by convenience sampling from outpatient services and medical wards of cardiology departments of a medical center in northern Taiwan. Data were collected for uncertainty, depressive symptoms, symptoms distress of heart failure, and HRQoL using self-report questionnaires. Demographics and clinical characteristics were analyzed with descriptive statistics. The mutual effects of disease characteristics, symptom distress, uncertainty in illness, depressive symptoms and HRQoL, as well as the overall model fitness, were analyzed by with structural equation modeling. We collected 147 qualified questionnaires. The mean score for the Mishel Uncertainty in Illness Scale for patients with heart failure was 73.5 (SD = 18.55); 65.3% of participants had a score of ≧13 on the Beck Depressive Inventory-II, indicating mild depression. Uncertainty, depressive symptoms, and HRQoL were directly related to symptom distress. Symptom distress and depressive symptoms were both mediators between uncertainty and depressive symptoms. Depressive symptoms also mediated emotional support and HRQoL. Uncertainty and depressive symptoms were important factors in the pathway between symptom distress and HRQoL for heart failure patients. We suggest providing heart failure patients with tailored interventions for effective self-management of symptoms based on Mishel's theory of uncertainty in illness, which could help control disease symptoms, alleviate uncertainty and depression as well as improve HRQoL.

Symptom Experience, Self-Care Adherence, and Quality of Life Among Heart Transplant Recipients in South Korea

Among heart transplant recipients, the perceived quality of life (QOL) is a key indicator of successful transplantation. QOL is affected by posttransplant treatments, including immunosuppressive therapy or self-care. However, few studies have evaluated QOL after heart transplantation in South Korea. This study aimed to investigate posttransplant symptoms associated with immunosuppressant, self-care adherence, and QOL in 105 heart transplant recipients in South Korea. Educational status (β = −1.05, p = .013), symptoms (β = −3.98, p = .004), and diet (β = 0.38, p < .001) were found to affect subjects’ overall QOL. In addition to these factors, caregivers and the duration of heart disease (years) were found to be influencing factors, depending on the individual QOL subdimension. These findings highlight the importance of controlling symptoms and managing medications as well as of self-care (particularly dietary compliance). Educational programs targeting beneficial changes in lifestyle, including diet, are needed.

Quality of life and uncertainty in Crohn's disease

INTRODUCTION

Crohn's disease impairs patients' perception of health and has a negative impact on health-related quality of life. Although it is apparent that uncertainty is a significant factor that decreases quality of life, it has never been studied in patients with Crohn's disease. The objective of the present study was to examine the association between level of certainty, self-epistemic authority, Internet information gathering habits, and health-related quality of life.

METHODS

A cross-sectional study of 105 Crohn's disease patients was conducted. Data were collected using a questionnaire composed of five parts: (1) demographic and clinical information; (2) health-related quality of life; (3) level of certainty; (4) self-epistemic authority; and (5) Internet information gathering habits regarding Crohn's disease.

RESULTS

A significant positive correlation was demonstrated between levels of certainty and health-related quality of life. Self-epistemic authority correlated positively with certainty, while information gathering via the Internet was related to decreased certainty. Multiple regression analysis for factors associated with health-related quality of life showed a positive association with the level of certainty, while negative associations were found between Internet information seeking and disease activity with the quality of life.

CONCLUSION

Level of certainty proved an important variable associated with health-related quality of life in Crohn's disease patients. Improving patients' self-epistemic authority can increase certainty and, thus, improve health-related quality of life.

The quality of information received by parents of children with chronic ill health attending hospitals as indicated by measures of illness uncertainty

BACKGROUND

The effectiveness of communication can be defined in terms of one of its outcomes: the uncertainty that it eliminates. Clear unambiguous communication is important for the parents of children to help them understand problems, explore alternative solutions and help make decisions. Persistent uncertainty is known to produce anxiety, unpredictable responses, emotional distress and poor quality of life. The uncertainty experienced by parents is one indicator of quality in the healthcare system which could have diagnostic and predictive value.

AIM

To assess the uncertainty experienced by parents of children with chronic conditions in the United Arab Emirates (UAE).

DESIGN

An exploratory descriptive, cross-sectional design was chosen across different sites in the UAE.

METHODS

Data were collected from parents accompanying children receiving treatment either as an inpatient or outpatient, using the previously validated, culturally adapted 'Parent Perception of Uncertainty Scale' (PPUS).

RESULTS

Most study participants experienced moderate or high levels of uncertainty. Parents who did not speak the local language, whose child was less than 1 year old or who was acutely ill had significantly more uncertainty than others, as did those parents whose child was approaching adolescence and puberty.

CONCLUSIONS

As only 5% of all participants reported low levels of uncertainty this should be of major concern as both an indicator of the quality of communication between health professionals and parents, and of the adverse health effects and poor quality of life experienced by parents of patients with chronic illness.

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.

Perceptions and experiences of patients living with implantable cardioverter defibrillators: a systematic review and meta-synthesis

Background

Sudden cardiac deaths have become a growing major public health concern that affects the world. Despite the various etiologies, life-threatening cardiac arrhythmias attribute the main cause of sudden cardiac deaths. Therefore in certain groups of high-risk patients, the Implantable Cardioverter Defibrillator (ICD) has been recommended as either a secondary or primary prophylactic method of prevention.

Objective

To summarise the perceptions of ICD recipients and provide an overview of their experiences with regards to the quality of life, coping strategies, and learning needs.

Methods

A systematic search was conducted using CINAHL, MEDLINE, PsycINFO, Scopus, Cochrane Library, and Web of Science. Primary research articles published from January 2005 to January 2016 that met the inclusion criteria were selected and assessed for methodological quality.

Results

Thirty-nine articles consisting of 16 qualitative studies, 22 quantitative studies, and 1 mixed methods study were included for the meta-synthesis. Findings extracted from these studies were grouped into eight subthemes with ‘living the ICD experience: a constant process of redefining oneself’ emerging as an over-arching theme.

Conclusion

This review provides insight into the perspectives and experiences of ICD recipients. Current evidence highlights the need for healthcare professionals to improve future care standards and develop a patient-centric holistic program that meets the specific needs of ICD recipients. Moreover, future studies are required to address the research gaps identified and also explore the perceptions of patients living with ICD in the Asian context.

Materials and fractal designs for 3D multifunctional integumentary membranes with capabilities in cardiac electrotherapy

Advanced materials and fractal design concepts form the basis of a 3D conformal electronic platform with unique capabilities in cardiac electrotherapies. Fractal geometries, advanced electrode materials, and thin, elastomeric membranes yield a class of device capable of integration with the entire 3D surface of the heart, with unique operational capabilities in low power defibrillation. Co-integrated collections of sensors allow simultaneous monitoring of physiological responses. Animal experiments on Langendorff-perfused rabbit hearts demonstrate the key features of these systems.

Living with an implantable cardiac defibrillator: a model of chronic uncertainty

Over the last two decades, the number of patients receiving implantable cardiac defibrillators (ICDs) for the prevention of sudden cardiac death has grown significantly. This growth is largely the result of broadened indication for ICD use because of the success of trials demonstrating efficacy. Early ICD indication centered on secondary prevention, which then advanced to primary prevention in high-risk patients. Nurses delivering care to these patients not only manage this complex technology but also patients' uncertainty about their survival and related psychosocial adjustment to receiving an ICD. To inform practice, theoretical models such as Mishel's (1988) uncertainty in illness model provide insight into such acute phases of illness. This article proposes expansion of the uncertainty in illness model to advance knowledge in this field for nurses caring for patients with ICD.

The relationships among satisfaction with social support, quality of life, and survival 5 to 10 years after heart transplantation

BACKGROUND

Despite the fact that social support has been found to be important to cardiovascular health, there is a paucity of information regarding the relationship between social support and outcomes long-term after heart transplantation (HT).

OBJECTIVES

Therefore, the purposes of our retrospective analyses of a prospective, longitudinal study were to examine (1) the relationship between satisfaction with social support and post-HT health-related quality of life (HRQOL) and survival and (2) whether 2 types of social support (emotional and tangible) were predictors of survival and HRQOL.

METHODS

Data were collected from 555 HT patients over a 5-year period (78% male, 88% white; mean age, 53.8 years at time of transplantation) at 4 US medical centers using the following instruments: Social Support Index, Quality of Life Index, Heart Transplant Stressor Scale, Jalowiec Coping Scale, and medical records review. Statistical analyses included t tests, correlations, Kaplan-Meier survival actuarials, and linear and multivariable regression.

RESULTS

Patients were very satisfied with overall social support from 5 to 10 years after HT (0 = very satisfied, 1 = very dissatisfied), which was stable across time (P = .74). Satisfaction with emotional social support (P = .53) and tangible social support (P = .61) also remained stable over time. When stratified into low, medium, and high levels of satisfaction, satisfaction with social support was not related to survival (P = .24). At 5 years, overall satisfaction with social support was a predictor of HRQOL (r = 0.59, P < .0001), and satisfaction with emotional social support was a predictor of HRQOL at 10 years after HT (r = 0.66, P < .0001).

CONCLUSIONS

Patients were very satisfied over time with emotional and tangible social support. While social support explained quality of life outcomes, it did not predict survival. Knowledge of relationships among social support, stress, and outcomes may assist clinicians to address social support needs and resources long-term after HT.

Psychometric properties of the Persian version of the Mishel's Uncertainty in Illness Scale in patients with cancer

PURPOSE

Uncertainty is a major component in the illness experiences which extraordinarily can affect the psychological adjustment and the illness outcomes. Uncertainty in illness is defined as inability to define the illness-related events to the illness or disability in predicting the illness outcomes. The present study aimed to translate the Persian version of Uncertainty in Illness Scale (MUIS-A) and to investigate its psychometric properties on patients with cancer.

METHOD

In this methodological study, validation of the Persian version of MUIS-A was performed in Iran on 420 cancer patients attending two major hospitals in Tehran, Iran. The scale was translated into Persian and back translated into English and revised according to editorial comments of the scale designers. Then, content and face validity, construct validity, internal consistency reliability and stability of the Persian version were measured. Data were analyzed using SPSS version 16 and LISREL 8.5.

RESULTS

Mean of the participants MUIS-A score was 90.1 (16.8). Confirmatory factor analysis confirmed validity of the whole instrument and its four subscales. The consistency of the instrument with a three-week interval was r = 0.91. Cronbach's alpha was 0.89 for the whole scale of 32 MUIS-A items and α = 0.58-0.86 for its four factors.

CONCLUSIONS

The Persian version of the MUIS-A has good psychometric properties. It can be used to assess uncertainty in illness in Iranian patients with cancer.

Patients' well-being: experience and actions in their preventing and handling of atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) influences the lives of patients in the form of worsened well-being. Patients' own experience of and how to handle AF is rarely investigated. These are important aspects for healthcare services to understand in order to support the well-being of patients with AF.

AIM

To explore and describe critical incidents in which patients experience how AF affects their well-being and what actions they take to prevent and handle it.

DESIGN AND METHODS

An explorative, descriptive design based on the critical incident technique (CIT) was used. Interviews were conducted with 25 patients (16 men and 9 women) with AF in a healthcare area in southern Sweden.

RESULTS

Patients experienced discomfort and limitations in daily life. The actions they took were self-care related actions and healthcare related actions.

CONCLUSION

AF affects well-being when it is uncomfortable and leads to pronounced limitations in daily life with the patients trying to maintain or restore well-being through adapting and developing strategies for self-care. Patients base the handling of AF on their personal experience.

Psychopathology in postinfarction patients implanted with cardioverter-defibrillators for secondary prevention. A cross-sectional, case-controlled study

OBJECTIVE

To determine (1) the incidence of anxiety and depression in patients implanted with defibrillators for secondary arrhythmia protection after myocardial infarction; (2) the effect of comorbidity and receipt of shock therapy on psychosocial maladjustment.

METHODS

Cross-sectional, one-off, questionnaire-based (HADS; MOS SF-36), case-controlled study of defibrillator recipients (n=100) from a 3-year implant period and three groups of matched controls [pacemaker (n=50), coronary intervention (n=50), atrial fibrillation (n=50)], sharing specific preselected previous health experiences. Spouses of each subgroup (n=106) were also studied. Although a cardiac rehabilitation program was available routinely for postinfarction patients, no specific rehabilitation was provided after defibrillator or pacemaker implant.

RESULTS

Mean scores for each assessment were similar for each group. Individual patient scores, however, revealed similarly high incidences of anxiety (24-34%) and depression (14-22%) in all groups. Experience of implantable cardioverter-defibrillator (ICD) 'shock(s)' and 'shock storm(s)' (≥ 3 shocks in 24 h) increased anxiety significantly. HADS criteria for anxiety 'caseness' or borderline 'caseness' were met in 63.6% of shock-storm recipients. Abnormal anxiety scores did not differ with interval from index event. Individual HADS scores also identified high incidences of anxiety in all spouse groups (25-48%).

CONCLUSIONS

Experience of shock storm precipitates pathological levels of anxiety in ICD recipients, and need for an ICD contributes to spouse anxiety. Individual CBT is indicated for patients who experience multiple shocks along with psycho-education for spouses. Anxiolytic and antidepressant medications may be indicated as part of their psychological rehabilitation.

Long-term follow-up study of uncertainty and psychosocial adjustment among implantable cardioverter defibrillator recipients

BACKGROUND

Sudden cardiac death is an international health issue. Implantable defibrillators have been effective in the secondary prevention of sudden cardiac death and are increasingly being utilized for primary prevention in individuals without a prior history of cardiac arrest or sustained ventricular tachycardia. Although it has been well documented that some recipients experience psychological distress and have difficulty in adjusting to the device, long-term data on psychological outcomes are limited.

OBJECTIVES

The aims of this study were to determine: (a) if there is a long-term relationship between uncertainty and psychosocial adjustment among implantable cardioverter defibrillator (ICD) recipients; and (b) if changes in uncertainty and/or adjustment occur over time.

DESIGN

A longitudinal, descriptive, correlational design was used for this long-term follow-up study (M=9.4 years, SD=.23).

SETTING AND PARTICIPANTS

Ninety-four patients from 4 major teaching hospitals in New England who had participated in an investigation of uncertainty and adjustment at 1 and 8 weeks following an initial ICD implant between 1996 and 1997 were solicited. From the original sample, 41 patients had expired (44%) and 5 had heart transplants (5%). Two individuals chose not to participate. Twenty-five persons (27%) were not found despite numerous attempts to locate them. The final sample included 21 subjects (22%).

METHODS

Following university institutional review board approval, a mail survey was administered using the Dillman method. Instruments included a demographic data questionnaire, the Psychosocial Adjustment to Illness Scale-Self-Report and the 2-factor version of the Mishel Uncertainty in Illness Scale.

RESULTS

The final sample primarily included educated, married, white males. Uncertainty and adjustment levels did not change significantly over time. Early adjustment explained 40% of the variance in overall adjustment at long-term follow-up (P=.010). Men experienced significantly more uncertainty overall [t(19)=2.925, P=.009] and complexity related to living with the device [t(19)=3.62, P=.002].

CONCLUSIONS

Patients should be screened for psychological distress prior to device implantation so early intervention can be provided. Qualitative research is recommended to determine whether gender specific needs related to living with an ICD exist. More quantitative, long-term longitudinal data are also needed.

A comparative study of uncertainty, optimism and anxiety in patients receiving their first implantable defibrillator for primary or secondary prevention of sudden cardiac death

BACKGROUND

Increasingly, patients are receiving implantable cardioverter defibrillators (ICDs) for prevention of sudden cardiac death. ICDs are implanted for primary prevention (patients at risk for ventricular arrhythmia [PP]) and secondary prevention (patients who have had/survived a sustained ventricular arrhythmia or cardiac arrest [SP]). Few prospective studies have examined psychosocial factors associated with these patients.

OBJECTIVES

To determine if patients receiving their first ICD for PP versus SP differed in uncertainty, anxiety, and optimism, before, 1 week, and 1 month after implant.

DESIGN

Prospective, descriptive, correlational pilot.

PARTICIPANTS AND SETTING

Fifteen PP and 15 SP patients receiving their first ICD were enrolled. Mean ages (+/- SD) were 65.7+/-11.3 and 67.9+/-7.7 respectively.

METHODS

Mishel's Uncertainty in Illness Scale (MUIS-C), State-Trait Anxiety Inventory (STAI) and the Life Orientation Test (LOT-R) were taken pre-implant, at the first post-implant visit, and at 1 month. Measures were compared using Student't-tests and ANOVA.

RESULTS

Pre-implant, both groups had moderately high MUIS-C scores (mean+/-SD; PP=67.67+/-13.36; SP=70.27+/-6.80; t=0.67; t(df)=28; p=0.507). LOT-R scores were 15.67+/-3.8 for PP and 16.47+/-3.6 for SP; t=0.59; t(df)=28; p=0.557. Pre-implant state anxiety scores were (mean PP=37.40+/-10.0, SP=37.73+/-13.6; t=0.076; t(df)=28; p=0.940). At 1-month PP patients had significantly lower uncertainty scores than the SP group (mean 62.33+/-4.17 versus 67.87+/-4.61; t=3.45; t(df)=28; p=0.002). A main effect for time, between pre-implant and 1-month, was found for uncertainty (F(2,56)=3.26; p<0.05) and state anxiety (F(2,56)=3.61, p<0.05), where both groups showed lower scores.

CONCLUSION

This study identified moderately high uncertainty in PP and SP patients prior to receiving their ICD. Though uncertainty was high, both groups reported an optimistic disposition and normal anxiety. At 1-month, SP patients had higher uncertainty scores than PP patients. This post-intervention uncertainty among patients who experienced an arrhythmic event warrants attention from nurses caring for ICD patients. Interventions to ameliorate uncertainty should be tailored to consider ICD indication.

A comparison of anxiety, depression and quality of life between device shock and nonshock groups in implantable cardioverter defibrillator recipients

BACKGROUND

Using standardized scales, we assessed the point prevalence, the severity of anxiety and depressive disorders, and the quality of life (QOL) in implantable cardioverter defibrillator (ICD) recipients who received a device shock.

METHODS

Forty research subjects with device shocks (Group 1) and 25 without shocks (Group 2) were interviewed after ICD implantation using the Mini International Neuropsychiatric Interview (MINI), the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

The point prevalence of anxiety disorders was higher in Group 1 (37.5%) than in Group 2 (8%) (P=.009). Depressive symptoms scores were higher in Group 1 (4.75) than in Group 2 (2.24) (P=.04)), but the prevalence of depressive disorders or the anxiety scores were not significantly different. A positive correlation was found between the number of shocks and the depressive symptoms scores (P=.05, r=0.24); there was a negative correlation between the mental health subscore of the SF-36 and the number of shocks (r=-0.36, P=.003). The point prevalence of depressive disorders was higher in the group with congenital cardiac diseases (50%) than in the valvular (8%) and ischemic groups (23%) (P=.04), and the mental health composite summary score of the SF-36 was lower in this group (46.34) than in those with valvular and ischemic disease (56.09 and 52.61, respectively) (P=.03).

CONCLUSION

Exposure to shocks may lead to an increased risk of anxiety and depressive symptoms. Research subjects receiving a high number of shocks and research subjects with congenital cardiovascular diseases were at higher risk of depressive symptoms or at higher risk of poorer psychological aspects of QOL.

Exploring uncertainty and psychosocial adjustment after cardioverter defibrillator implantation

BACKGROUND

Sudden cardiac death is a leading cause of death in the Americas and Europe. Although the implantable cardioverter defibrillator (ICD) has decreased mortality from sudden cardiac death, it may be associated with psychosocial adjustment (PSA) problems and be a source of uncertainty for some recipients. The purpose of this study was to explore uncertainty and PSA among first-time ICD recipients during the first 2 months after hospital discharge.

METHODS

Ninety-four adult, first-time ICD recipients recruited from 4 New England hospitals were studied at 1 week (S1) and 8 weeks (S2) after hospital discharge using a repeated-measures, correlational survey design. Mishel Uncertainty in Illness Scale, Psychosocial Adjustment to Illness Scale, and a demographic questionnaire were administered. Data were analyzed using descriptive and inferential statistics, including Pearson correlations, repeated-measures analysis of variance, multivariate canonical analysis, multiple regression, hierarchical regression, and 1-way analysis of variance.

RESULTS

There was no change in the nature or level of uncertainty over time. Uncertainty at S1 explained a significant amount (39%) of the variance in overall PSA at S2. Psychosocial adjustment domains at S1 explained a large proportion (62%) of the variance in overall PSA at S2. Education, employment status, and functional status were related to uncertainty. Younger recipients, people with a lower functional status, and those with disability had more PSA problems. Time since discharge was not correlated with uncertainty or PSA. Uncertainty was a strong predictor of PSA at both S1 and S2.

CONCLUSIONS

First-time ICD recipients who have greater uncertainty or less PSA at 1 week after hospital discharge may have more PSA problems during the first 2 months after implant. Age, education, and severity of illness may influence uncertainty and/or PSA. Further research is needed to determine the relationship between uncertainty and PSA over time.

Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography

Background Little is known about illness-related uncertainty and decreased health-related quality of life in patients undergoing initial coronary angiography or about the long-term effects of uncertainty.

Objectives To compare patients with and without high levels of uncertainty before angiography and to examine the influence of uncertainty on health-related quality of life 1 year after angiography.

Methods In a prospective, longitudinal study, measurements of perceived control, uncertainty, affective distress, and health-related quality of life were collected from 93 patients before angiography (baseline) and 1 year later. At baseline, patients were classified into high- and low-uncertainty groups by median split. At 1 year, analysis of variance was used to compare health-related quality of life and psychological outcomes in the 2 groups, and multiple linear regression with stepwise entry was used to identify independent determinants of health-related quality of life.

Results Compared with patients with low baseline uncertainty, patients with high baseline uncertainty had higher levels of anxiety and depression and lower levels of perceived control and health-related quality of life 1 year after angiography. Baseline health-related quality of life, uncertainty, and life stress accounted for 54% of the variance in health-related quality of life, even when angiographic outcome was controlled for (P &lt; .001). Baseline uncertainty was independently associated with health-related quality of life (β = −0.25; 95% confidence interval, −9.40 to −0.05; P = .02).

Conclusions At initial angiography, high levels of uncertainty about illness portend negative health-related quality of life outcomes up to 1 year later.

Plateau waveform shape allows a much higher patient shock energy tolerance in AF patients

OBJECTIVES

To evaluate the possible pain reduction of the plateau waveform in atrial fibrillation (AF) patients.

BACKGROUND

Previous studies have indicated that reduced amplitude waveforms would be less painful than a conventional (65/65% tilt) biphasic waveform. Computer modeling suggested that a moderately long (10-12 msec) plateau (flat topped) shock waveform would deliver equivalent effectiveness with the lowest possible peak amplitude.

METHODS

We enrolled 27 patients at two sites with persistent AF with a total of 220 shocks delivered during internal atrial cardioversion using an interleaved crossover design. Patient response was scored in three ways: (1) a verbally reported discomfort score, (2) visual analog scale (VAS), and (3) a blinded observer reporting a contraction score.

RESULTS

All scores were significantly reduced (P < 0.0001) by the plateau waveform with impressive statistics: Verbal discomfort (3.51 +/- 0.13 to 2.89 +/- 0.12), VAS (7.00 +/- 0.56 to 5.91 +/- 0.36), and contraction scores (1.94 +/- 0.12 to 1.62 +/- 0.12). The average pain threshold shift (TS) for the Verbal score was 2.34, while that for the VAS score was 2.30. (This means that the patient typically could tolerate 2.34 times as much energy with the plateau waveform for the same level of verbally reported discomfort.) The contraction TS was less at 1.57. Response scores were also corrected for the shock sequence number to control for the sensitization effect from multiple shocks. This increased the TS for the Verbal score to 3.58, but the shock number was not significant for the VAS. A pulmonary artery electrode return was associated with lower pain compared with a coronary sinus position.

CONCLUSION

A plateau shaped biphasic waveform resulted in significantly increased shock energy pain tolerances. Controlling for session sensitization, patients tolerated over three times as much energy for the same verbally reported discomfort score.

Living With an Implantable Cardioverter Defibrillator

BACKGROUND AND PURPOSE

Life-threatening cardiac dysrhythmias that cause sudden cardiac death claim more than a thousand lives a day. Many sudden cardiac death survivors and those at high risk receive an implantable cardioverter defibrillator (ICD). Despite the large number of people living with an ICD, little is known about their ICD knowledge and the impact of this knowledge on their uncertainty and quality of life (QOL). The purpose of this study was to determine if ICD knowledge and uncertainty predict QOL in individuals living with an ICD.

METHODS

A purposive sample of 90 ICD recipients was recruited from a large rural Northeastern cardiac clinic. A descriptive correlational design was used. Multiple regression analysis was used to assess relationships among ICD knowledge, uncertainty, and QOL. Confounding variables of age, education, left ventricular ejection fraction, and number of years postimplantation were controlled in the analyses.

RESULTS AND CONCLUSIONS

Statistically significant relationships were found between uncertainty and QOL, but ICD knowledge was not significantly related to uncertainty or QOL. Younger recipients reported a lower QOL. Education, ejection fraction, number of ICD shocks since implantation, and number of months since implantation were unrelated to ICD knowledge, uncertainty, or QOL in these ICD recipients. It is important to evaluate ICD recipients' understanding of the information they receive and to determine what ICD knowledge, uncertainty, and QOL means from the patient's perspective to assist them in the transitional process of learning to live with an ICD.