Patients' knowledge and concerns about using the implantable cardioverter defibrillator for the primary prevention of sudden cardiac death and its correlates: A cross‐sectional study

Background and Aims

Methods

Results

Conclusion

Experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to synthesize the best available qualitative evidence on the everyday life experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease.

INTRODUCTION

Cardiovascular disease is a rising concern worldwide. The efficacy of the implantable cardioverter defibrillator as a successful treatment for cardiovascular disease has been well documented. Research suggests that living with an implantable cardioverter defibrillator is complex and can cause substantial psychosocial distress that can manifest itself at various intervals over time. The first step to developing evidence-based recommendations related to the management of implantable cardioverter defibrillator-related distress is a critical appraisal and synthesis of relevant literature to gain a more comprehensive understanding of this phenomenon.

INCLUSION CRITERIA

The participants of interest were adults 18 years or older who had an implantable cardioverter defibrillator for the management of cardiovascular disease (e.g. ischemic heart disease, angina, cardiomyopathy, myocardial infarction, congenital defect, arrhythmias, heart failure). The phenomenon of interest was the everyday life experience of adults living with an implantable cardioverter defibrillator. The review considered all qualitative research related to the phenomenon of interest.

METHODS

Key databases searched were PubMed, CINAHL, PsycINFO, Embase, International Bibliography of the Social Sciences, Sociological Abstracts, OpenGrey, MedNar, ProQuest Dissertations and Theses Global, Google, and Google Scholar. Published and unpublished papers and articles from 1990 to July 2018 were included in the search. The JBI approach to critical appraisal, study selection, data extraction, and synthesis for qualitative research was used throughout the review.

RESULTS

Twenty-seven papers were included in the review that yielded 143 findings and 13 categories. The methodological quality of the 27 included studies was moderate to strong. Based on ConQual scores, confidence in the synthesized findings was moderate. From this, three synthesized findings were extracted: i) living under the shadow of uncertainty, ii) orchestrating a new normal, and iii) crafting a positive vision for the future.

CONCLUSIONS

Evidence suggests that while implantable cardioverter defibrillator recipients do experience psychosocial distress, they gradually positively embrace the device as part of their everyday norm. Recommendations for practice and education point to the further development of best practice guidelines for implantable cardioverter defibrillator management, continuing education programs for health care providers, and strategies to support implantable cardioverter defibrillator recipients and their families to cope with the device. Research that examines onset, level, and duration of implantable cardioverter defibrillator psychosocial distress is needed to target specific interventions reflective of this population's needs. While findings suggest the experiences of women living with an implantable cardioverter defibrillator are similar to men, the low number of women in included studies limits the strength of this conclusion.

Driving following defibrillator implantation: development and pilot results from a nationwide questionnaire

BACKGROUND

Implantable cardioverter defibrillator (ICD) implantation is associated with driving restrictions which may have profound effects on the patient's life. However, there is limited patient-reported data on the information given about driving restrictions, the adherence to the restrictions, the incidence of arrhythmic symptoms while driving, and the driving restrictions' effect on ICD patients' daily life and quality of life factors. A specific questionnaire was designed to investigate these objectives, intended for use in a nationwide ICD cohort.

METHODS

The conceptual framework based on literature review and expert opinion was refined in qualitative semi-structured focus group interviews with ten ICD patients. Content validity was pursued through pre-testing, including expert review and 28 cognitive interviews with patients at all ICD implanting centres in Denmark. Finally, the Danish Pacemaker and ICD registry was used to randomly select 50 ICD patients with a first-time implantation between January 1, 2013 and November 30, 2016 for pilot testing, followed by a test-retest on 25 respondents. Test-retest agreement was assessed using kappa statistics or intraclass correlation coefficients.

RESULTS

The pilot test achieved a response rate of 78%, whereof the majority were web-based (69%). Only 49% stated they had been informed about any driving restrictions after ICD implantation, whereas the number was 75% after appropriate ICD shock. Among respondents, 95% had resumed private driving, ranging from 1 to 90 days after ICD implantation. In those informed of a significant (≥ 1 month) driving ban, 55% stated the driving restrictions had impeded with daily life, especially due to limitations in maintaining employment or getting to/from work and 25% admitted they had knowingly been driving during the restricted period. There were six episodes of dizziness or palpitations not necessitating stopping the vehicle. Test-retest demonstrated good agreement of questionnaire items, with 69% of Kappa coefficients above 0.60.

CONCLUSIONS

We have developed a comprehensive questionnaire on ICD patients' perspective on driving. Pre-testing and pilot testing demonstrated good content validity, feasible data collection methods, and a robust response rate. Thus, we believe the final questionnaire, distributed to almost 4000 ICD patients, will capture essential evidence to help inform driving guidelines in this population.

Driving restrictions for Dutch patients with an implantable cardioverter defibrillator : Compliance and associated factors

Background

Dutch patients with an implantable cardioverter defibrillator (ICD) are restricted from driving for two months after implantation or shocks. This requires significant lifestyle adjustments and is one of the primary concerns of ICD patients. Previous studies indicated that compliance with the driving restrictions is poor, but insight in socio-demographic, clinical and psychological factors associated with compliance is limited. Hence, this study aimed to explore compliance with the driving restrictions and associated factors in a large sample of Dutch ICD patients.

Method

Dutch ICD patients (N = 313) completed an elaborative set of questionnaires at time of implantation and at four months after implantation, assessing socio-demographic, psychological and driving-related characteristics. Clinical data were collected from the patients’ medical records.

Results

A substantial subgroup (28%) of the patient sample (median age 64 (interquartile range = 55–71), 81% male) reported to have been noncompliant with the driving restrictions. Univariate analysis indicated that noncompliant patients more often considered refusing the ICD due to the restrictions, compared to compliant patients (19% versus 10%, p = 0.02). Multivariate analysis showed that the feeling of understanding the reason behind the driving restrictions was associated with better compliance (odds ratio = 2.16, 95% confidence interval 1.02–4.56, p = 0.04). No other socio-demographic, clinical, psychological or driving-related factors were associated with compliance.

Conclusion

A large number of ICD patients does not comply with the driving restrictions after implantation. This study emphasised the importance of the patient’s feeling of understanding the reason behind the restrictions.

Exploring the Patient's Experiences of Learning to Live with an Implantable Cardioverter Defibrillator (ICD) from One UK Centre: A Qualitative Study

BACKGROUND

International expansion of indications for implantable cardioverter defibrillator (ICD) implant means increasing numbers of patients with devices worldwide. However, smaller numbers of patients with ICDs in the UK has meant that clinical expertise available to care for this specialized group is limited. Whilst North American patients' experiences of living with an ICD are well documented, European perspectives remain underrepresented.

AIM

The aim of this study was to explore and describe patient's experiences around the time of their ICD device implant and after they returned home from one UK centre.

METHODS AND RESULTS

Eligible patients were recruited from one regional cardiothoracic centre and interviewed in their own homes using semi-structured schedules. Analysis of data elicited three themes; non-individualised nature of information, adjustments to living with the device and future outlook. Unique findings identified were; (a) concealment of concerns and symptoms; (b) funding issues; and (c) unavailability of appropriate support and advice during and after time in hospital.

CONCLUSION

Individualized care and support for these ICD patients appeared lacking according to respondents. Opportunities to discuss concerns appeared non-existent, which may indicate that UK patients are disadvantaged in the domain of psychological support compared with their European and North American counterparts. Findings remain tentative until explored with a larger, more representative and international sample.

Partners of ICD Patients—An Exploratory Study of Their Experiences

BACKGROUND

The experiences of partners who care for and support the needs of a loved one with an implantable cardiac defibrillator (ICD) remain largely unknown within Europe.

AIMS

This study explored the nature of partner's experiences from the pre-ICD implantation phase up until a maximum of 20 months at home.

METHODS

Eight partners cohabiting with a recipient of an ICD were interviewed using a semistructured schedule. All interviews were transcribed and content analysed for emerging categories and themes.

FINDINGS

Four themes representing 11 categories conceptualised the partners' experiences, these included: Acknowledging the patient's need for the device, reactions to the device, safeguarding the patient, and returning to normality.

CONCLUSION

This qualitative study suggests that partners of ICD recipients progress through various difficult and adaptive stages when learning how best to support the patient. A point is reached when most are able to assume control and normalise their lives. This transformation is slow; however, to improve this process and empower partners, nurses should provide relevant information and include them in decisions affecting the patient. Further research into the unique needs of partners, which includes international perspectives, would be significant in developing practice and theory in this area.

Patients, intimate partners and family experiences of implantable cardioverter defibrillators: qualitative systematic review

AIM

This paper is a report of an interpretive review of qualitative research on how an implantable cardioverter defibrillator affects adult recipients and their significant others.

BACKGROUND

An implantable cardioverter defibrillator detects pathological cardiac rhythms and automatically converts the rhythm with electrical counter shocks.

DATA SOURCES

A systematic literature search was conducted for qualitative research papers published between January 1999 and January 2009. PubMed, Medline, ISI Web of Knowledge and CINAHL databases were searched with the following key words: internal defibrillator, implantable defibrillator and qualitative research.

REVIEW METHODS

Twenty-two papers were included. The critical appraisal skills programme and prompts were used to appraise studies. Thematic analysis and synthesis approaches were used to interpret evidence.

FINDINGS

People with an implantable cardioverter defibrillator were found to experience physical, psychological and social changes. Shocks produce fear and anxiety, affecting relationships and sexual relations. The use of support groups and the use of the Internet are important in helping adjustment to an implantable cardioverter defibrillator. Women's responses to an implantable cardioverter defibrillator appear different than men's responses and include concerns about physical appearance and relationship issues. Postdischarge follow-up and educational programmes are still underdeveloped.

CONCLUSION

Patients need additional education, support and follow-up care after hospital discharge. Patients and significant others benefit from collaboration between patient associations and healthcare professional societies. Future research is needed to identify the specific challenges that women recipients face.

[The daily experience of the patient with an implantable cardioverter defibrillator]

OBJECTIVE

To describe the daily experience of patients with an automatic defibrillator (AD) implant and the adaptive changes of the patient.

METHOD

Qualitative and phenomenological research. Collection of data through; initially unstructured interview with half of the informants, semi-structured interviews through an open questions guide after the initial unstructured interviews and use of personal narratives of the informants. Analysis of the data using the Van Manen proposal.

RESULTS

We analysed the interviews of 10 participants. We collected socio-demographic variables and identified the following themes, which respond to the question "How is life with an AD": It is life "with the two sides of the coin," living in constant wait and uncertainty, accepting change, developing adaptation strategies, renegotiating relationships and sexuality and it is to live transformed.

CONCLUSIONS

The results of this study can be integrated into nurse clinical practice in areas such as valuation after discharge, changes in habits, control of treatment, notification of shocks, masking detection of symptoms and strategies that can jeopardise the bearer. Research needs to be developed that looks closer into the influence of other technological devices in people.

Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators

Patients with an implantable cardioverter defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions vary across different countries in Europe. The most recent recommendations for driving of ICD patients in Europe were published in 1997 and focused mainly on patients implanted for secondary prevention. In recent years there has been a vast increase in the number of patients with an ICD and in the percentage of patients implanted for primary prevention. The EHRA task force on ICD and driving was formed to reassess the risk of driving for ICD patients based on the literature available. The recommendations are summarized in the following table and are further explained in the document. [table: see text] Driving restrictions are perceived as difficult for patients and their families, and have an immediate consequence for their lifestyle. To increase the adherence to the driving restrictions, adequate discharge of education and follow-up of patients and family are pivotal. The task force members hope this document may serve as an instrument for European and national regulatory authorities to formulate uniform driving regulations.

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.

Can nurses in cardiology areas prepare patients for implantable cardioverter defibrillator implant and life at home?

This study explored nurses' confidence and competence in preparing patients for having an implantable cardioverter defibrillator implanted and for life at home after discharge. Whilst research has identified various physical and psychosocial effects to patients and their partners associated with device implant and subsequent lifestyle adjustments, no research has explored nurses' knowledge of the device or these effects. A survey was designed using a purposive sample of 152 nurses from cardiology areas in four large teaching hospitals and a 28-point postal questionnaire to explore knowledge of the device and its impact. Most subjects were not confident in their abilities to prepare patients for implant or life at home after implant. Knowledge of the device and its effects appeared poorly understood by all nurses, irrespective of additional qualifications, length of time since qualifying or area of work. Many participants were aware of the poor knowledge level of nurses and identified it as a weakness in current care practices. Lack of understanding may impair preparation of patients for implantation of or for living with an implantable cardioverter defibrillator, and feasible strategies to change this situation will require careful consideration and further investment.