Psychological distress in patients with an implantable cardioverter defibrillator and their partners

Efficacy of a web-based healthcare innovation to advance the quality of life and care of patients with an implantable cardioverter defibrillator (ACQUIRE-ICD): a randomized controlled trial

AIMS

Modern clinical management of patients with an implantable cardioverter defibrillator (ICD) largely consists of remote device monitoring, although a subset is at risk of mental health issues post-implantation. We compared a 12-month web-based intervention consisting of goal setting, monitoring of patients' mental health-with a psychological intervention if needed-psychoeducational support from a nurse, and an online patient forum, with usual care on participants' device acceptance 12 months after implantation.

METHODS AND RESULTS

This national, multi-site, two-arm, non-blinded, randomized, controlled, superiority trial enrolled 478 first-time ICD recipients from all 6 implantation centres in Denmark. The primary endpoint was patient device acceptance measured by the Florida Patient Acceptance Survey (FPAS; general score range = 0-100, with higher scores indicating higher device acceptance) 12 months after implantation. Secondary endpoints included symptoms of depression and anxiety. The primary endpoint of device acceptance was not different between groups at 12 months [B = -2.67, 95% confidence interval (CI) (-5.62, 0.29), P = 0.08]. Furthermore, the secondary endpoint analyses showed no significant treatment effect on either depressive [B = -0.49, 95% CI (-1.19; 0.21), P = 0.17] or anxiety symptoms [B = -0.39, 95% CI (-0.96; 0.18), P = 0.18].

CONCLUSION

The web-based intervention as supplement to usual care did not improve patient device acceptance nor symptoms of anxiety and depression compared with usual care. This specific web-based intervention thus cannot be recommended as a standardized intervention in ICD patients.

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.

The development of a decision aid for shared decision making in the Dutch implantable cardioverter defibrillator patient population: A novel approach to patient education

Background

Counseling of Implantable Cardioverter-defibrillator (ICD) patients with regard to individual risks and benefits is challenging. An evidence-based decision aid tailored to the needs of Dutch ICD patients is not yet available. The objective of this pilot project was to structurally evaluate the current clinical practice in The Netherlands and the ICD patient experience, in order to develop an online decision aid to facilitate shared decision making in ICD procedures.

Methods

Between June 2016 and December 2017, a Dutch web-based decision aid was developed according to the Patient Decision Aid Standards (IPDAS) using the RAND-UCLA/multi-stepped Delphi model. Development process consisted of 5 stages in which the Dutch clinical practice was reviewed (stage 1), patients’ needs and their history of decision making was structurally assessed (stages 2A and B) and a modified Delphi consensus process was performed with an expert panel consisting of representatives from different medical fields (stage 3). Results from stages 1–3 were used to design and structure the content of an online-based decision aid (stage 4) which was finally evaluated in a usability testing by patients in stage 5.

Results and conclusion

This study describes the evidence-based approach to the development of the Dutch ICD decision aid. In our population, levels of shared decision-making experience were low. The ICD decision aid was structurally developed for the Dutch ICD patient population. Our upcoming multicenter stepped wedge clustered randomized trial will further evaluate the ICD decision aid in clinical practice.

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.

Profiles of partner health linked to a partner-focused intervention following patient initial implantable cardioverter defibrillator (ICD)

This study examined differential responses among partners who participated in a RCT designed to compare two social cognitive theory interventions, one designed for patients only (P-only) and one for patients and their intimate partners (P + P). The interventions were delivered following the patient receiving an initial ICD implant. Partner health outcomes were examined longitudinally from baseline at hospital discharge to 3, 6, and 12 months. Outcomes included 6 measures: partner physical and mental health status (Short-Form-36 PCS and MCS), depression (Patient Health Questionnaire-9), anxiety (State-Trait Anxiety Inventory), caregiver burden (Oberst Caregiver Burden Scale), and self-efficacy in ICD management (Sudden Cardiac Arrest Self-efficacy scale). Growth mixture and mixed effect modeling were used to identify and compare trajectories of 6 health outcomes within the P-only and P + P arms of the study. Partners (n = 301) were on average 62 years old, female (74.1%) and Caucasian (83.4%), with few co-morbidities (mean Charlson Co-morbidity index, 0.72 ± 1.1). Two types of profiles were observed for P-only and P + P, one profile where patterns of health outcomes were generally better across 12 months and one with outcome patterns that were generally worse across time. For PCS, no significant partner differences were observed between P-only or P + P in either the better (p = 0.067) or the worse (p = 0.129) profile types. Compared to P-only, partners in the worse profile improved significantly over 12 months in MCS (p = 0.006), caregiver burden P + P (p = 0.004) and self-efficacy P + P (p = 0.041). Compared to P-only, P + P partners in the low anxiety profile improved significantly (p = 0.001) at 3 months. Partners with more psychosocial distress at hospital discharge benefited most from the P + P intervention. Among partners with generally low levels of anxiety, those in the P + P intervention compared to P-only showed greater improvement in anxiety over 12 months.

Advance care planning and end-of-life care in patients with an implantable cardioverter defibrillator: The perspective of relatives

BACKGROUND

Little is known about the last phase of life of patients with implantable cardioverter defibrillators and the practice of advance care planning in this population.

AIM

To describe the last phase of life and advance care planning process of patients with an implantable cardioverter defibrillator, and to assess relatives' satisfaction with treatment and care.

DESIGN

Mixed-methods study, including a survey and focus group study.

SETTING/PARTICIPANTS

A survey among 170 relatives (response rate 59%) reporting about 154 deceased patients, and 5 subsequent focus groups with 23 relatives.

RESULTS

Relatives reported that 38% of patients had a conversation with a healthcare professional about implantable cardioverter defibrillator deactivation. Patients' and relatives' lack of knowledge about device functioning and the perceived lack of time of healthcare professionals were frequently mentioned barriers to advance care planning. Twenty-four percent of patients experienced a shock in the last month of life, which were, according to relatives, distressing for 74% of patients and 73% of relatives. Forty-two to sixty-one percent of relatives reported to be satisfied with different aspects of end-of-life care, such as the way in which wishes of the patient were respected. Quality of death was scored higher for patients with a deactivated device than those with an active device (6.74 vs 5.67 on a 10-point scale, p = 0.012).

CONCLUSIONS

Implantable cardioverter defibrillator deactivation was discussed with a minority of patients. Device shocks were reported to be distressing to patients and relatives. Relatives of patients with a deactivated device reported a higher quality of death compared to relatives of patients with an active device.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Pathogenesis and management of Brugada syndrome in schizophrenia: A scoping review

CONTEXT

Excess cardiovascular morbidity and an increased prevalence of sudden cardiac death (SCD) contributes to premature mortality in schizophrenia. Brugada syndrome (BrS) is an important but underrecognized cause of SCD. It is more commonly seen in schizophrenia than in general population controls.

METHODS

We conducted a scoping review to describe the pathogenesis of BrS in schizophrenia and to identify the psychotropic medications that increase the risk of unmasking BrS and associated ventricular arrhythmias resulting in SCD.

FINDINGS

Schizophrenia and BrS share similar calcium channel abnormalities, which may result in aberrant myocardial conductivity. It remains uncertain if there is a genetic pre-disposition for BrS in a subset of patients with schizophrenia. However, the unmasking of Brugada ECG patterns with the use of certain antipsychotics and antidepressants increases the risk of precipitating SCD, independent of QT prolongation.

CONCLUSIONS AND FUTURE DIRECTIONS

Specific cardiology assessment and interventions may be required for the congenital or unmasked Brugada ECG pattern in schizophrenia. The current long-term standard of care for BrS is an implantable cardioverter defibrillator (ICD), but post-implantation psychological effects must be considered. Careful use of antipsychotic and other psychotropic medications is necessary to minimize proarrhythmic effects due to impact on cardiac sodium and calcium ion channels. When prescribing such drugs to patients with schizophrenia, clinicians should be mindful of the potentially fatal unmasking of Brugada ECG patterns and how to manage it. We present recommendations for psychiatrists managing this patient population.