Association between anxiety and mortality in patients with congestive heart failure after implantation of cardiac electronic devices

OBJECTIVE

Several studies suggest that psychological factors including anxiety are associated with negative outcomes and in particular higher mortality rates among heart failure (HF) patients. However, the impact of anxiety on mortality in patients with implanted cardiac devices has not been fully appreciated. The aim of this study was to assess the association between state (SA) and trait (TA) anxiety and all-cause mortality in patients with HF after cardiac electronic devices implantation.

METHODS

The monocentric prospective study enrolled 265 patients (215 men and 50 women) aged 23 to 84 years (mean age 57.1 ± 10.0), who received cardiac resynchronization therapy or cardioverter-defibrillator implantation. Mean duration of prospective follow-up was 62.3 ± 36.6 months. State-Trait Anxiety Inventory (STAI) was used to measure anxiety symptoms. Cox proportional hazards multivariate regression model was used to calculate hazard ratio (HR) of all-cause mortality with 95% confidence interval (95% CI).

RESULTS

During the prospective follow-up period, 45 (17.0%) patients died due to all causes. According to quantitative analysis, HR for death used for SA scale was 1.04 (95% CI 1.00-1.07, p = 0.07) and for the TA scale 1.02 (95% CI 0.99-1.05, p = 0.21). Analysis of categorical indicators found statistically significant higher HR of mortality in patients with severe SA (2.35, 95% CI 1.17-4.71, p = 0.02), and TA (2.02, 95% CI 1.04-3.94, p = 0.04).

CONCLUSION

High levels of SA and TA was significantly and independently associated with a high risk of all-cause mortality in patients, who underwent implantation of cardiac electronic devices.

Quality of life, depression, and anxiety in patients with a subcutaneous versus transvenous defibrillator system

BACKGROUND

Use of the subcutaneous implantable defibrillator (S-ICD) has increased because the device received US Food and Drug Administration approval in 2012, but we still know little about whether the quality of life (QoL) of patients with an S-ICD versus a transvenous ICD (TV-ICD) is comparable. We compared S-ICD patients with TV-ICD patients on QoL, depression, and anxiety up to 12 months' follow-up.

METHODS

A matched cohort of S-ICD (N = 167) and TV-ICD patients (N = 167) completed measures on QoL, depression, anxiety, and personality at baseline, 3, 6, and 12 months post implant. Data were analyzed using multivariable modeling with repeated measures.

RESULTS

In adjusted analyses, we found no statistically significant differences between cohorts on physical and mental QoL and depression (all Ps > .05), while S-ICD patients reported lower anxiety than TV-ICD patients (P = 0.0007). Both cohorts experienced improvements in physical and mental QoL and symptoms of depression and anxiety over time (all Ps < .001), primarily between implant and 3 months. These improvements were similar for both cohorts with respect to physical and mental QoL and anxiety (Ps > .05), while S-ICD patients experienced greater reductions in depressive symptoms (P = .0317).

CONCLUSION

The QoL and depression levels were similar in patients with an S-ICD and a TV-ICD up to 12 months' follow-up, while S-ICD patients reported lower anxiety levels and a greater reduction in depression over time as compared to TV-ICD patients. This knowledge may be important for patients and clinicians, if the indication for implantation allows both the S-ICD and the TV-ICD, making a choice possible.

Patient-Reported Quality of Life as a Predictor of Mortality and Ventricular Tachyarrhythmia's During 7 Years' Follow-Up in Patients With an Implantable Cardioverter Defibrillator (from the MIDAS Study)

Preliminary evidence suggests that poor patient-reported quality of life (QoL) predicts mortality on the short term in patients with an implantable cardioverter defibrillator (ICD). It is unclear if this association persists on the long term. We evaluated whether patient-reported QoL at the time of implantation predicts mortality and ventricular tachyarrhythmias (VTa's) during 7 years' follow-up in patients with an ICD. A consecutive cohort of patients (80% men; mean [SD] age = 58 [12]) implanted with an ICD completed the Short Form Health Survey (SF-36). The 8 SF-36 subscales and the 2 component summary scores were used as predictors of VTa's and mortality at 7 years' follow-up. At 7 years' follow-up, 34% (132/392) of patients had died. Baseline physical functioning (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11 to 2.29), role physical functioning (HR: 1.59; 95% CI: 1.09 to 2.31), vitality (HR: 1.53; 95% CI: 1.05 to 2.22), and general health (HR: 1.57; 95% CI: 1.09 to 2.27) were associated with 7-year mortality in adjusted analyses. There was a trend for low mental health being associated with an increased risk of mortality (HR: 1.38; 95% CI: 0.98 to 1.96). The other SF-36 dimensions were not significantly associated with mortality. Only baseline social functioning was associated with risk of VTa's during follow-up. In conclusion, patients with lower levels of physical functioning, role physical functioning, vitality, or general health had a greater risk of mortality, whereas only poor social functioning was associated with VTa's during 7 years' follow-up. Patient-reported QoL at the time of implant could be used to identify patients at risk for long-term mortality.

Living with an implantable cardioverter defibrillator: patients' preferences and needs for information provision and care options

Aims

The clinical management and care of patients with an implantable cardioverter defibrillator (ICD) has shifted from face-to-face in-clinic visits to remote monitoring. Reduced interactions between patients and healthcare professionals may impede patients' transition to adapting post-implant. We examined patients' needs and preferences for information provision and care options and overall satisfaction with treatment.

Methods and results

Patients implanted with a first-time ICD or defibrillator with cardiac resynchronization therapy (n = 389) within the last 2 years at Odense University Hospital were asked to complete a purpose-designed and standardized set of questionnaires. The level of satisfaction with information provision was high; only 13.1% were dissatisfied. Psychological support for patients (39.9%), their relatives (43.1%), and deactivation of the ICD towards end of life (47.8%) were among the top five topics that patients reported to have received no information about. The top five care options that patients had missed were talking to the same healthcare professional (75.2%), receiving ongoing feedback via remote monitoring (61.1%), having a personal conversation with a staff member 2-3 weeks post-implant (59.6%), having an exercise tolerance test (52.5%), and staff asking how patients felt while hospitalized (50.4%). Patients with a secondary prevention indication and cardiac arrest survivors had specific needs, including a wish for a psychological consult post-discharge.

Conclusion

Despite a high satisfaction level with information provision, particular topics are not broached with patients (e.g. device activation) and patients have unmet needs that are not met in current clinical practice.

Effectiveness of a comprehensive interactive eHealth intervention on patient-reported and clinical outcomes in patients with an implantable cardioverter defibrillator [ACQUIRE-ICD trial]: study protocol of a national Danish randomised controlled trial

BACKGROUND

In Denmark and other countries, there has been a shift in the management of patients with an implantable cardioverter defibrillator (ICD) with remote device monitoring largely replacing in-hospital visits. Less patient-nurse and patient-physician interaction may lead to gaps in patients' quality of care and impede patients' adaptation to living successfully with the ICD. A comprehensive eHealth intervention that include goal-setting, monitoring of symptoms of depression, anxiety, and quality of life, psychological treatment, information provision, supportive tools, online dialogues with nursing staff and access to an online community network, may help fill these gaps and be particularly beneficial to patients who suffer from anxiety and depression. This study will evaluate the effectiveness of the ACQUIRE-ICD care innovation, a comprehensive and interactive eHealth intervention, on patient-reported and clinical outcomes.

METHODS

The ACQUIRE-ICD study is a multicenter, prospective, two-arm, unblinded randomised controlled superiority trial that will enroll 478 patients implanted with a first-time ICD or ICD with cardiac synchronisation therapy (CRT-D) from the six implanting centers in Denmark. The trial will evaluate the clinical effectiveness and cost-effectiveness of the ACQUIRE-ICD care innovation, as add-on to usual care compared with usual care alone. The primary endpoint, device acceptance, assessed with the Florida Patient Acceptance Survey, is evaluated at 12 months' post implant. Secondary endpoints, evaluated at 12 and 24 months' post implant, include patient-reported outcomes, return to work, time to first ICD therapy and first hospitalisation, mortality and cost-effectiveness.

DISCUSSION

The effectiveness of a comprehensive and interactive eHealth intervention that relies on patient-centred and personalised tools offered via a web-based platform targeted to patients with an ICD has not been assessed so far. The ACQUIRE-ICD care innovation promotes and facilitates that patients become active participants in the management of their disease, and as such addresses the need for a more patient-centered disease-management approach. If the care innovation proves to be beneficial to patients, it may not only increase patient empowerment and quality of life but also free up time for clinicians to care for more patients.

TRIAL REGISTRATION

The trial has been registered on https://clinicaltrials.gov/ct2/show/NCT02976961 on November 30, 2016 with registration number [ NCT02976961 ].

Optimism as predictor of patient-reported outcomes in patients with an implantable cardioverter defibrillator (data from the WEBCARE study)

OBJECTIVE

The implantable cardioverter defibrillator (ICD) is the treatment of choice for prevention of sudden cardiac death. However, a subgroup of ICD patients experiences psychological adjustment problems post implant. To date, positive psychological constructs (e.g. optimism) have been understudied in this population. Hence, we examined the association between optimism and anxiety, depression, and health status at 12-months post implant.

METHODS

Patients (N=171) enrolled in the WEB-based distress management study for ICD patients were included in the analyses. Optimism and pessimism (LOT), and Type D personality (DS14) were administered at baseline, while anxiety (GAD-7), depression (PHQ-9), and health status (SF-12) were assessed at 12-months.

RESULTS

The mean age was 59.6±10.06 with 81% being male. After controlling for demographic, personality, and clinical variables, baseline optimism was associated with lower anxiety (β=-0.210; p=0.011) and depression (β=-0.222; p=0.005), and better physical (β=0.227; p=0.004) and mental health status (β=0.350; p=0.000) at follow-up. Optimism was also associated with change in mental health status (β=0.195; p=0.007) but not with change in anxiety, depression, and physical health status at follow-up.

CONCLUSIONS

Our findings indicate that optimism is associated with less distress and possibly helps safeguard mental health in ICD patients. Increase optimism might be the way forward to reduce long-term distress and impaired health status.

TRIAL REGISTRATION

http://www.ClinicalTrials.gov. Identifier: NCT00895700.

Sleep disturbance in patients with an implantable cardioverter defibrillator: Prevalence, predictors and impact on health status

Background:

Sleep disturbances are highly prevalent in patients with cardiac diseases and associated with poor health outcomes. However, little is known about sleep disturbance in patients with an implantable cardioverter defibrillator.

Aims:

We examined the prevalence and predictors of sleep disturbance and the impact on perceived health status in a Dutch cohort of implantable cardioverter defibrillator patients.

Methods:

Patients (n=195) enrolled in the Web-based distress program for implantable cardioverter defibrillator patients (WEBCARE) trial completed questionnaires at the time of implantable cardioverter defibrillator implantation, three, six and 12 months afterwards. Sleep disturbance was assessed with the corresponding item #3 of the Patient Health Questionnaire 9.

Results:

At baseline, 67% (n=130) reported sleep disturbance (cut off ≥1). One year later, the prevalence was 57% (n=112). Younger age (odds ratio=0.96, 95% confidence interval 0.92–0.99; p=0.012) and high negative affectivity/low social inhibition (odds ratio=4.47, 95% confidence interval 1.52–13.17; p=0.007) were associated with sleep disturbance at 12 months in adjusted analyses. Sleep disturbance was not associated with health status at 12 months. Charlson Comorbidity Index, anxiety, Type D personality and high negative affectivity/low social inhibition were associated with impaired health status at follow-up.

Conclusions:

Sleep disturbance was highly prevalent in patients with an implantable cardioverter defibrillator. Younger age and high negative affectivity predicted sleep disturbance 12 months post-implantation independent of other demographic, clinical, intervention and psychological covariates. Sleep disturbance was not associated with impaired health status at the 12-month follow-up.

The role of the Arrhythmia Team, an integrated, multidisciplinary approach to treatment of patients with cardiac arrhythmias: results of the European Heart Rhythm Association survey

Management of patients with cardiac arrhythmias is increasingly complex because of continuous technological advance and multifaceted clinical conditions associated with ageing of the population, the presence of co-morbidities and the need for polypharmacy. The aim of this European Heart Rhythm Association Scientific Initiatives Committee survey was to provide an insight into the role of the Arrhythmia Team, an integrated, multidisciplinary approach to management of patients with cardiac arrhythmias. Forty-eight centres from 18 European countries replied to the Web-based questionnaire. The presence of an Arrhythmia Team was reported by 44% of the respondents, whereas 17% were not familiar with this term. Apart from the electrophysiologist, health professionals who should belong to such teams, according to the majority of the respondents, include a clinical cardiologist, a nurse, a cardiac surgeon, a heart failure specialist, a geneticist, and a geriatrician. Its main activity should be dedicated to the management of patients with complex clinical conditions or refractory or inherited forms of arrhythmias. When present, the Arrhythmia Team was considered helpful by 95% of respondents; the majority of centres (79%) agreed that it should be implemented. The Arrhythmia Team seems to be connected to important expectations in the management of cardiac arrhythmias. The efficacy of such an integrated and multidisciplinary approach should be encouraged and tested in clinical practice.

E-health to manage distress in patients with an implantable cardioverter-defibrillator: primary results of the WEBCARE trial

The Web-based distress management program for patients with an implantable cardioverter-defibrillator (ICD; WEBCARE) was developed to mitigate distress and enhance health-related quality of life in ICD patients. This study investigated the treatment effectiveness at 3-month follow-up for generic and disease-specific outcome measures.

METHODS

Consecutive patients implanted with a first-time ICD from six hospitals in the Netherlands were randomized to either the "WEBCARE" or the "usual care" group. Patients in the WEBCARE group received a 12-week fixed, six-lesson behavioral treatment based on the problem-solving principles of cognitive behavioral therapy.

RESULTS

Two hundred eighty-nine patients (85% response rate) were randomized. The prevalence of anxiety and depression ranged between 11% and 30% and 13% and 21%, respectively. No significant intervention effects were observed for anxiety (β = 0.35; p = .32), depression (β = -0.01; p = .98) or health-related quality of life (Mental Component Scale: β = 0.19; p = .86; Physical Component Scale: β = 0.58; p = .60) at 3 months, with effect sizes (Cohen d) being small (range, 0.06-0.13). There were also no significant group differences as measured with the disease-specific measures device acceptance (β = -0.37; p = .82), shock anxiety (β = 0.21; p = .70), and ICD-related concerns (β = -0.08; p = .90). No differences between treatment completers and noncompleters were observed on any of the measures.

CONCLUSIONS

In this Web-based intervention trial, no significant intervention effects on anxiety, depression, health-related quality of life, device acceptance, shock anxiety, or ICD-related concerns were observed. A more patient tailored approach targeting the needs of different subsets of ICD patients may be warranted.

TRIAL REGISTRATION

clinicaltrials.gov. Identifier: NCT00895700.

Monitoring treatment expectations in patients with an implantable cardioverter-defibrillator using the EXPECT-ICD scale

AIMS

Patient treatment expectations may affect cardiac outcomes; however, till date, no validated instruments have been developed to monitor treatment expectations in patients with an implantable cardioverter-defibrillator (ICD). This study evaluates the predictive value of the newly developed 10-item EXPECtations Towards ICD therapy (EXPECT-ICD) in relation to anxiety, depression, and ICD related concerns 3 months post-implant.

METHODS AND RESULTS

Consecutive implanted ICD patients were included as part of the WEB-based distress management programme for ICD patients (WEBCARE) trial from six Dutch referral hospitals. The patients completed the baseline questionnaires briefly after ICD implantation. Information on clinical variables was captured from the patients' medical records. Patients' treatment expectations as assessed with the EXPECT-ICD questionnaire could best be represented with a two-factor model involving both negative (α = 0.84) and positive expectations (α = 0.77) with a score range of 0-20 for each factor. Negative treatment expectations were associated with higher levels of anxiety (β = 0.443; P < 0.001), depression (β = 0.506; P < 0.001), and ICD concerns (β = 0.428; P < 0.001) 3 months post-implant after controlling for demographic and clinical factors. Positive expectations were not related to any of the distress outcomes.

CONCLUSION

Negative expectations were associated with anxiety, depression, and ICD concerns 3 months post-implant. The current findings indicate that the EXPECT-ICD scale is a reliable, valid, and disease-specific measure of the treatment expectations in ICD patients. Future research needs to investigate whether addressing the patients' expectations might improve the outcome and the subjective well-being of ICD patients.

Attrition and adherence in a WEB-Based Distress Management Program for Implantable Cardioverter defibrillator Patients (WEBCARE): randomized controlled trial

Background

WEB-Based Distress Management Program for Implantable CARdioverter defibrillator Patients (WEBCARE) is a Web-based randomized controlled trial, designed to improve psychological well-being in patients with an implantable cardioverter defibrillator (ICD). As in other Web-based trials, we encountered problems with attrition and adherence.

Objective

In the current study, we focus on the patient characteristics, reasons, and motivation of (1) completers, (2) those who quit the intervention, and (3) those who quit the intervention and the study in the treatment arm of WEBCARE.

Methods

Consecutive first-time ICD patients from six Dutch referral hospitals were approached for participation. After signing consent and filling in baseline measures, patients were randomized to either the WEBCARE group or the Usual Care group.

Results

The treatment arm of WEBCARE contained 146 patients. Of these 146, 34 (23.3%) completed the treatment, 88 (60.3%) dropped out of treatment but completed follow-up, and 24 (16.4%) dropped out of treatment and study. Results show no systematic differences in baseline demographic, clinical, or psychological characteristics between groups. A gradual increase in dropout was observed with 83.5% (122/146) completing the first lesson, while only 23.3% (34/146) eventually completed the whole treatment. Reasons most often given by patients for dropout were technical problems with the computer, time constraints, feeling fine, and not needing additional support.

Conclusions

Current findings underline the importance of focusing on adherence and dropout, as this remains a significant problem in behavioral Web-based trials. Examining possibilities to address barriers indicated by patients might enhance treatment engagement and improve patient outcomes.

Trial Registration

Clinicaltrials.gov: NCT00895700; http://www.clinicaltrials.gov/ct2/show/NCT00895700 (Archived by WebCite at http://www.webcitation.org/6NCop6Htz).