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Inayat S, Aziz F, Younas A, Durante A. Determinants of Sexual Health and Sexual Quality of Life after Cardiovascular Surgeries: An Integrative Review. Heart Lung Circ 2024:S1443-9506(24)00657-7. [PMID: 38969608 DOI: 10.1016/j.hlc.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 05/13/2024] [Accepted: 05/23/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND AIM Sexual health and sexual quality of life are key components of psychosocial adjustment after cardiac surgeries and are often linked with improving the general quality of life. Reviews have been conducted to highlight the associations between cardiovascular diseases and sexual dysfunctions, but no review reported determinants of sexual health and sexual quality of life in patients after cardiovascular surgeries. We aimed to comprehensively examine the determinants of sexual health and sexual quality of life among individuals with cardiovascular surgeries. METHODS Literature was searched within PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 816 records were identified from database searches, 279 records were screened, and 11 empirical studies were included for review. Relevant data were extracted using literature summary tables and synthesised using an inductive approach. RESULTS The core determinants of sexual health and sexual quality of life were type of surgery and comorbidities, fears and uncertainties regarding sexual activity, sexual health education and counselling, spousal relationship and communication, and demographic factors such as advanced age and literacy levels. Major surgeries performed were coronary artery bypass grafting (CABG) and heart valve surgeries. The data collection tools used to collect data for sexual health and sexual quality of life were the International Erectile Function Questionnaire (IEFQ), International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Sexual Knowledge CABG Scale (SKS-CABG), Sexual Quality of Life Questionnaire (SQOL), SKS-Myocardial Infarction Scale (SKS-MI), and Couple Communication Scale (CCS). CONCLUSIONS Despite their importance, sexual health and quality of life are frequently overlooked during patient rehabilitation after cardiovascular surgeries. The lack of adequate education and counselling from healthcare professionals frequently leads to increased fear and uncertainties among individuals and their partners. Therefore, more person-centred educational and counselling approaches should be developed to address the sexual concerns of individuals and their partners.
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Affiliation(s)
- Shahzad Inayat
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Faisal Aziz
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, Graz, Styria, Austria; Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Styria, Austria
| | - Ahtisham Younas
- Faculty of Nursing, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada.
| | - Angela Durante
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; SITRA, Fondazione Toscana G. Monasterio, Pisa and Massa, Italy
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Ziapour A, Kazeminia M, Rouzbahani M, Bakhshi S, Montazeri N, Yıldırım M, Tadbiri H, Moradi F, Janjani P. Global prevalence of sexual dysfunction in cardiovascular patients: a systematic review and meta-analysis. Syst Rev 2024; 13:136. [PMID: 38769586 PMCID: PMC11103881 DOI: 10.1186/s13643-024-02525-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Sexual dysfunction poses a significant challenge for patients with cardiac conditions. Concerning the prevalence of sexual disorders in cardiovascular patients, several seminal studies conducted in various regions of the world have provided diverse facts and figures pertaining to sexual dysfunction among cardiovascular patients. Therefore, the present study aimed to analyze, summarize, and integrate the findings of seminal studies on the effect of underlying factors and estimate the global rate of sexual disorders in cardiovascular patients. METHODS The present systematic review and meta-analysis included studies conducted in 2003-2023. To find the relevant published academic papers, SID, MagIran, PubMed, Scopus, Web of Science (WOS), and Google Scholar databases were searched for keywords using MeSH/Emtree until January 14, 2023. The GRADEpro software was used to evaluate the quality of evidence. The heterogeneity of studies was checked using the I2 index. RESULTS An initial number of 2122 studies were found in the first search. Following a precise screening process based on predefined inclusion criteria, a total of 17 studies were deemed suitable for inclusion in the meta-analysis. The global prevalence of sexual disorders in cardiovascular patients was estimated at 62.6% (95% CI: 49.8-73.8%). As the results of the meta-regression showed that as the sample size increased, there was a significant decrease in the overall prevalence of sexual disorders among cardiovascular patients. Additionally, as the study years progressed, both age and JBI score exhibited an upward trend. CONCLUSION The present findings showed a high prevalence of sexual disorders among cardiovascular patients. Therefore, it is recommended that experts and health policymakers enhance their focus on effectively preventing and controlling these disorders. Besides the evidence achieved very low certainty, it is important for the treatment team to prioritize the sexual relations of cardiovascular patients and focus on improving their sexual function. This should be seen as an essential aspect of their overall recovery process.
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Affiliation(s)
- Arash Ziapour
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Rouzbahani
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeedeh Bakhshi
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nafiseh Montazeri
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Murat Yıldırım
- Department of Psychology, Faculty of Science and Letters, Agri Ibrahim Cecen University, Ağrı, Türkiye
- Graduate Studies and Research, Lebanese American University, Beirut, Lebanon
| | - Hani Tadbiri
- Islamic Azad University, Tehran Medical Branch, Tehran, Iran
| | - Farideh Moradi
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Parisa Janjani
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Park JJ, Doo SW, Kwon A, Kim DK, Yang WJ, Song YS, Shim SR, Kim JH. Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis. World J Mens Health 2023; 41:330-341. [PMID: 36593706 PMCID: PMC10042662 DOI: 10.5534/wjmh.220124] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/31/2022] [Accepted: 08/10/2022] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD. MATERIALS AND METHODS Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool. RESULTS The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226-0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308-1.039) at one month and 0.320 (95% CI, 0.074-0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance. CONCLUSIONS This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.
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Affiliation(s)
- Jae Joon Park
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Seung Whan Doo
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Allison Kwon
- Department of Biochemistry, College of Biological Science, University of California, Davis, CA, USA
| | - Do Kyung Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Won Jae Yang
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yun Seob Song
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Sung Ryul Shim
- Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, Changwon, Korea.
| | - Jae Heon Kim
- Department of Urology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
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Pike A, Dobbin-Williams K, Swab M. Experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease: a systematic review of qualitative evidence. JBI Evid Synth 2021; 18:2231-2301. [PMID: 32813405 DOI: 10.11124/jbisrir-d-19-00239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
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.
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Affiliation(s)
- April Pike
- Memorial University of Newfoundland, Faculty of Nursing, St. John's, NL, Canada.,Memorial University Faculty of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A JBI Affiliated Group, St. John's, NL, Canada
| | - Karen Dobbin-Williams
- Memorial University of Newfoundland, Faculty of Nursing, St. John's, NL, Canada.,Memorial University Faculty of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A JBI Affiliated Group, St. John's, NL, Canada
| | - Michelle Swab
- Memorial University Faculty of Nursing Collaboration for Evidence-Based Nursing and Primary Health Care: A JBI Affiliated Group, St. John's, NL, Canada.,Memorial University of Newfoundland, Health Sciences Library, St. John's, NL, Canada
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Streur MM, Rosman LA, Sears SF, Steinke EE, Thompson EA, Dougherty CM. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020; 17:892-902. [PMID: 32198104 DOI: 10.1016/j.jsxm.2020.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sexual concerns and changes in sexual activity are common among patients and their intimate partners after an implantable cardioverter defibrillator (ICD). AIMS Our aims were to (i) describe patient and partner sexual activity and related concerns from the time of an initial ICD implant through 12-month follow-up and (ii) identify factors predictive of return to sexual activity and fears associated with sexual activity. METHODS This secondary descriptive analysis was conducted with data from a randomized controlled trial (2009-2015) designed to compare 2 interventions for patients (Patient-Only) and for patients and their partners (Patient+Partner) after implant of an initial ICD. The sample included 105 patients and their intimate partners who reported sexual activity during the 24 months before ICD implant. OUTCOMES The Sexual Concerns Inventory was used to assess sexual activity and related concerns. RESULTS Study participants comprised 72% male and were of mean age 65.6 ± 10.6 years; partners comprised 64% female and were of mean age 63 ± 11.6 years. Sexual activity increased after ICD: 73% of patients reported no sexual intercourse during 2 months before study enrollment, whereas only 46% reported no sexual intercourse during the 2 months before 12-month follow-up. Reductions in sexual concerns were evident 1 month after implant, with continued reductions through 12 months (patient 6.48 ± 4.03 to 5.22 ± 3.38, P = .004; partner 6.93 ± 4.01 to 5.2 ± 3.56, P < .001). Patient physical health predicted sexual activity 3 months after implant placement (P = .04); general ICD concerns (P < .001) predicted patient ICD-related sexual fears at 3 months. At 12 months, baseline general ICD concerns (P < .02) predicted sexual fears. CLINICAL IMPLICATIONS ICD patients and partners report low levels of sexual activity at the time of initial ICD implant, with reported increases in sexual activity over the 12-month recovery period: Sexual concerns were highest immediately after ICD implant. STRENGTHS & LIMITATIONS Notably, the major strengths of this study were the repeated measures and longitudinal study design; the main limitation of the study was the lack of a "usual care" control group. CONCLUSION Sexual activity at the time of an initial ICD implant is low, and sexual concerns are most prominent for both patients and partners immediately after implant placement. Baseline physical health predicts subsequent sexual activity at 3 months, while general ICD-related worry predicts sexual fears at 3 and 12 months. Streur MM, Rosman LA, Sears SF, et al. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020;17:892-902.
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Affiliation(s)
- Megan M Streur
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA.
| | - Lindsey A Rosman
- Division of Cardiology, Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Samuel F Sears
- Department of Psychology, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC, USA
| | - Elaine E Steinke
- School of Nursing, College of Health Professions, Wichita State University, Wichita, KS, USA
| | - Elaine A Thompson
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
| | - Cynthia M Dougherty
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA.
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Streur MM, Thompson EA, Dougherty CM. Multisymptom Profile Predicts Increased Risk of Poor Outcomes After Initial Placement of Implantable Cardioverter Defibrillator. J Pain Symptom Manage 2020; 59:658-667. [PMID: 31707069 PMCID: PMC7024646 DOI: 10.1016/j.jpainsymman.2019.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 11/30/2022]
Abstract
CONTEXT Patients with implantable cardioverter defibrillators (ICDs) are at risk for multiple physical and psychological symptoms. Identification of specific symptom profiles associated with poor outcomes may elucidate novel strategies to enhance symptom management. OBJECTIVES The objectives were to determine common symptoms after initial ICD implantation, identify classes of individuals with similar symptom profiles, describe patient characteristics associated with different symptom profiles, and determine if symptom profiles at hospital discharge predicted outcomes three and 12 months after implantation. METHODS This was a secondary data analysis of a randomized controlled trial that compared patient + partner versus patient-only interventions designed to help patients manage symptoms, prepare for ICD shocks, and resume daily activities. Symptoms were measured with the Patient Concerns Assessment. Latent class regression analysis was used to identify symptom classes at baseline, three-month, and 12-month follow-up. Associations between patient characteristics, class membership, and outcomes were examined using chi-square, analysis of variance, and Poisson regression. RESULTS The study included 301 patients (74% male, mean age 64 ± 11.9 years). Three classes were identified: Multi-Symptom (N = 119, 40%), Tired-Rundown (N = 130, 43%), and Mostly Asymptomatic (N = 52, 17%). Patients in the Multi-Symptom class were younger (59.9 years, P < 0.001) and reported more anxiety (P < 0.001) and depression (P < 0.01) than the other classes. Membership in the Multi-Symptom class predicted lower quality of life and resulted in nearly double the rate of hospitalizations after 12 months (P = 0.02, IRR 1.9). CONCLUSION Evaluation of symptom profiles after ICD implantation offers a promising strategy for identifying patients at risk for poor health outcomes.
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Affiliation(s)
- Megan M Streur
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Elaine A Thompson
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Cynthia M Dougherty
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington, USA.
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Palm P, Zwisler AD, Svendsen JH, Giraldi A, Rasmussen ML, Berg SK. Compromised Sexual Health Among Male Patients With Implantable Cardioverter Defibrillator: A Cross-Sectional Questionnaire Study. Sex Med 2019; 7:169-176. [PMID: 30674447 PMCID: PMC6522935 DOI: 10.1016/j.esxm.2018.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/31/2018] [Accepted: 12/04/2018] [Indexed: 01/03/2023] Open
Abstract
Introduction In cardiac patients with implantable cardioverter defibrillator (ICD), sexual function is sparsely described. Aim To determine the prevalence and distribution of sexual dysfunction, and to describe whether primary or secondary prophylactic ICD indication and antitachycardia pacing (ATP) or shock is associated with sexual function. Methods A cross-sectional survey of men with an implanted ICD was conducted at 2 university hospitals in Denmark. Inclusion criteria were men over the age of 18 with an ICD. Exclusion criterion was no partner. Main Outcome Measure Sexual function was assessed by the International Index of Erectile Function questionnaire and data on implantation indication (primary/secondary prevention) and therapy such as ATP and shock (both appropriate and inappropriate) was obtained from the Danish ICD Register. Results Data from 415 questionnaires were analyzed (response rate 50.2%). Patients had a mean age of 63.9±12.1 years. Erectile dysfunction (ED) was present in 70% of patients, orgasmic dysfunction was present in 57.9% of patients, 82.8% had reduced sexual desire, 85.8% had intercourse satisfaction problems, and 76.9% experienced overall satisfaction problems (non-validated metric except for ED). Patients with an ICD on primary prophylactic indication had more sexual dysfunction and ED compared with patients with an ICD on secondary prophylactic indication. ATP therapy, but not shock, was associated with more ED. Conclusion Sexual dysfunction is common in patients with ICD and is not limited to ED, but also orgasmic function, desire, intercourse, and overall satisfaction are affected. Primary prophylactic ICD indication and ATP, but not shock therapy, is associated with compromised sexual function. Palm P, Zwisler A-D, Svendsen JH. Compromised Sexual Health Among Male Patients With Implantable Cardioverter Defibrillator: A Cross-Sectional Questionnaire Study. Sex Med 2019;7:169–176.
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Affiliation(s)
- Pernille Palm
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Ann-Dorthe Zwisler
- The National Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Nyborg, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Annamaria Giraldi
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Sexological Clinic, Psychiatric Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Linnet Rasmussen
- Department of Nursing, Faculty of Health and Technology, Metropolitan University College, Copenhagen, Denmark
| | - Selina Kikkenborg Berg
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Palm P, Zwisler ADO, Svendsen JH, Thygesen LC, Giraldi A, Jensen KG, Lindschou J, Winkel P, Gluud C, Steinke E, Berg SK. Sexual rehabilitation for cardiac patients with erectile dysfunction: a randomised clinical trial. Heart 2018; 105:775-782. [DOI: 10.1136/heartjnl-2018-313778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/03/2022] Open
Abstract
BackgroundSexual dysfunction is common in patients with either ischaemic heart disease (IHD) or implantable cardioverter defibrillator (ICD) and has a negative impact on quality of life. Non-pharmacological treatment options are lacking. The purpose of this trial was to assess the effect of sexual rehabilitation versus usual care for males with erectile dysfunction and either IHD and/or ICD.MethodsParticipants with erectile dysfunction and IHD and/or ICD were randomised to 12 weeks of sexual rehabilitation consisting of physical exercise training, pelvic floor exercise and psychoeducation, or usual care. Primary outcome: sexual function by the International Index of Erectile Function (IIEF). Secondary outcome: sexual function by the Psychosocial Adjustment to Illness Scale. Exploratory outcomes: exercise capacity, pelvic floor strength/endurance, self-reported health and mental health.Results154 participants were included, mean age 61.6 years (SD 6.1). Sexual rehabilitation compared with usual care improved sexual function with a mean difference IIEF score of 6.7 (95% CI 3.1 to 10.4, p<0.0003) at 4 months between groups (unadjusted IIEF mean scores 36.4 vs 31.3) and a mean difference of 6.7, 95% CI 3.2 to 10.1 (p<0.0002) at 6 months between groups (unadjusted mean scores IIEF 37.1 vs 32.2). No effects were seen on the secondary outcome. Sexual rehabilitation improved exercise capacity on cycle ergometer measured by Watt max with a mean difference of 10.3, 95% CI 3.6 to 16.9 (p<0.003) and pelvic floor strength (p<0.01). No differences were seen on self-reported health and mental health.ConclusionSexual rehabilitation compared with usual care improves sexual function and exercise capacity.Trial registrationNCT01796353; Results.
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Dougherty CM, Thompson EA, Kudenchuk PJ. Patient plus partner trial: A randomized controlled trial of 2 interventions to improve outcomes after an initial implantable cardioverter-defibrillator. Heart Rhythm 2018; 16:453-459. [PMID: 30340060 DOI: 10.1016/j.hrthm.2018.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Interventions to improve physical and psychological outcomes in recipients with an initial implantable cardioverter-defibrillator (ICD) and their intimate partners are largely unstudied, though likely to have a major impact on adjustment to the ICD and general well-being. OBJECTIVE The purpose of this study was to report the primary outcomes of the patient plus partner randomized controlled trial. METHODS In a 2-group (N = 301) prospective randomized controlled trial, we compared 2 social-cognitive-based intervention programs-patient plus partner (P+P) and patient only (P only)-implemented after initial ICD implantation. The patient intervention, consisting of educational materials, nurse-delivered telephone coaching, videotape demonstrations, and access to a nurse via a 24/7 pager, was implemented in both groups. P+P also incorporated partner participation. The primary patient outcomes were symptoms and anxiety at 3 months. Other outcomes were physical function (SF-36 [Short Form 36] and ICD shocks-patient), psychological adjustment (PHQ-9 [Patient Health Questionaire-9]), relationship impact (Dyadic Adjustment Scale and Oberst Caregiving Burden Scale (DAS and OCBS) partner), self-efficacy and knowledge (Sudden Cardiac Arrest-Self Efficacy [SCA-SE], Sudden Cardiac Arrest-Outcomes Expectation [SCA-OE], and Knowledge Self-Assessment [KSA]), and health care utilization (outpatient visits and hospitalizations) at hospital discharge and 1, 3, 6, and 12 months post-ICD implantation. RESULTS For patients, P+P compared with P only was more effective in improving symptoms (P = .02), depression (P = .006), self-efficacy (P = .02), outcome expectations (P = .03), and knowledge (P = .07). For partners, P+P was more effective in improving partner caregiver burden (P = .002), self-efficacy (P = .001), and ICD knowledge (P = .04). CONCLUSION An intervention that integrated the partner into the patient's recovery after an ICD improved outcomes for both. Beyond survival benefits of the ICD, intervention programs designed to address both the patient and their partner living successfully with an ICD are needed and promising.
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Affiliation(s)
- Cynthia M Dougherty
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle, Washington.
| | - Elaine A Thompson
- Psychosocial and Community Health, University of Washington School of Nursing, Seattle, Washington
| | - Peter J Kudenchuk
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington
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Hudec Š, Špaček M, Hutyra M, Moravec O, Táborský M. Sexual activity and cardiovascular disease, erectile dysfunction as a predictor of ischemic heart disease. COR ET VASA 2018. [DOI: 10.1016/j.crvasa.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mornar Jelavić M, Krstačić G, Perenčević A, Pintarić H. Sexual Activity in Patients with Cardiac Diseases. Acta Clin Croat 2018; 57:141-148. [PMID: 30256023 PMCID: PMC6400344 DOI: 10.20471/acc.2018.57.01.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
SUMMARY – In this article, we outline the latest guidelines published by the American Heart Association on sexual activity in patients with coronary artery disease, heart failure, structural heart diseases, arrhythmias, implanted pacemakers or cardioverter defibrillators, as well as on treatment options of sexual dysfunction. Sexual activities are similar to mild/moderate physical activity during a short period. Most patients are recommended to involve in sexual activity after prior comprehensive evaluation of physical condition. Those with stable cardiac symptoms and good functional capacity are at a low risk of adverse cardiovascular events, and others require treatment or stabilization before involving in sexual activity. Stress testing is useful in evaluating safety of sexual activity in patients with questionable or undetermined risk. Treatment of sexual dysfunction includes counseling of patients and their sexual partners, and drug treatment with phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) which have been demonstrated to be safe and effective, in men, and with serotonin reuptake inhibitors (flibanserin) and local vaginal estrogen administration in women. In conclusion, in routine clinical practice, patients should be approached individually and multidisciplinarily in order to detect and eliminate the factors that interfere with normal sexual activities and disturb the quality of life.
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Affiliation(s)
| | - Goran Krstačić
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia.,School of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Aleksandra Perenčević
- Department of Internal Medicine and Dialysis, Zagreb-East Health Center, Zagreb, Croatia
| | - Hrvoje Pintarić
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia.,Cardiac Catheterization Laboratory, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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Gallagher R, Potter E, Thomson Mangnall L, Ladak L, Gallagher P, Neubeck L. The power in being together for young adults who have heart disease - the photoshoot experience. Heart Lung 2017; 46:199-204. [PMID: 28366291 DOI: 10.1016/j.hrtlng.2017.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 02/12/2017] [Accepted: 02/16/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The study aimed to determine perceived motivations and benefits of photoshoot participation for young adults who have heart disease. BACKGROUND Feeling isolated and different can have lifelong affects on quality of life in heart disease survivors. Photoshoots, where people create a photographic image of themselves, promote positive interpretation of their cardiac illness experience, but participant experiences remain under-investigated. METHODS Young adult heart disease support group members completing a photoshoot were interviewed and data were thematically analyzed. RESULTS Seven females and one male aged 20-47 years participated. The main theme, People Like Me, emphasized feelings of being different, isolated and uncertain due to the heart disease. Other themes related to support gained from people who were not like them, gaining and providing support to their peers. The photoshoot enabled a highly valued collective feeling. CONCLUSIONS For young adult heart disease survivors, the photoshoot provides a fun, social opportunity to reduce isolation and share experiences.
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Affiliation(s)
- Robyn Gallagher
- Sydney Nursing School and Charles Perkins Centre, University of Sydney, Rm 2210, Lvl 2, Bld 17, Camperdown, NSW 2007, Australia; Faculty of Health, University of Technology, Sydney, 15 Broadway, Ultimo, NSW 2007, Australia.
| | - Ellen Potter
- Sydney Nursing School and Charles Perkins Centre, University of Sydney, Rm 2210, Lvl 2, Bld 17, Camperdown, NSW 2007, Australia
| | - Linda Thomson Mangnall
- Sydney Nursing School and Charles Perkins Centre, University of Sydney, Rm 2210, Lvl 2, Bld 17, Camperdown, NSW 2007, Australia; Cardiac Telemetry Unit, Sydney Adventist Hospital, 185 Fox Valley Rd Wahroonga, NSW 2076, Australia
| | - Laila Ladak
- Sydney Nursing School and Charles Perkins Centre, University of Sydney, Rm 2210, Lvl 2, Bld 17, Camperdown, NSW 2007, Australia
| | | | - Lis Neubeck
- Sydney Nursing School and Charles Perkins Centre, University of Sydney, Rm 2210, Lvl 2, Bld 17, Camperdown, NSW 2007, Australia; The George Institute of Global Health, Lvl 3, 50 Bridge St, Sydney, NSW 2000, Australia
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Longitudinal changes in quality of life following ICD implant and the impact of age, gender, and ICD shocks: observations from the INTRINSIC RV trial. J Interv Card Electrophysiol 2017; 48:291-298. [PMID: 28220279 DOI: 10.1007/s10840-017-0233-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE ICDs can improve survival in at-risk patients but no consensus exists with respect to their impact on health-related quality of life (QOL). Moreover, the data are unclear on QOL benefits in specific patient subgroups. We sought to analyze, in the INTRINSIC RV ICD trial population, health-related QOL longitudinally following ICD implant and consider impact of age, gender, and ICD shocks on QOL by employing a global measure of health-related QOL. METHODS One thousand five hundred thirty patients had an ICD implanted. One week after implant (n = 1461), 988 patients were randomized to DDDR with AV search hysteresis (n = 502) or VVI (n = 486) programming. QOL data, using the SF-36 short form, were obtained for the 1461 patient cohort, irrespective of randomization status, at baseline and prospectively for 1 year following ICD implant. RESULTS Longitudinal mixed-effect analyses revealed significant improvements from baseline across all SF-36 subscales and component scores for the overall study cohort. Women had a substantially lower QOL at baseline, although their improvement after implant was similar to men. Patients <50 years scored consistently worse at baseline but experienced the greatest QOL improvement versus other age groups. Patients with higher NYHA class, angina, and diabetes had greater QOL improvements. There was no significant difference in QOL between patients with and without ICD shocks. CONCLUSIONS Our findings indicate that QOL was reportedly better post-implant and suggest that benefits associated with ICD implantation go beyond the direct treatment of arrhythmias, with benefits seen across genders and different age groups. These results further highlight that ICD implantation, in and of itself, does not reduce QOL.
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Muehrer RJ, Lanuza DM, Brown RL, Djamali A. Development and Psychometric Testing of a Sexual Concerns Questionnaire for Kidney Transplant Recipients. J Nurs Meas 2015; 23:499-518. [PMID: 26673773 DOI: 10.1891/1061-3749.23.3.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE This study describes the development and psychometric testing of the Sexual Concerns Questionnaire (SCQ) in kidney transplant (KTx) recipients. METHODS Construct validity was assessed using the Kroonenberg and Lewis exploratory/confirmatory procedure and testing hypothesized relationships with established questionnaires. Configural and weak invariance were examined across gender, dialysis history, relationship status, and transplant type. Reliability was assessed with Cronbach's alpha, composite reliability, and test-retest reliability. RESULTS Factor analysis resulted in a 7-factor solution and suggests good model fit. Construct validity was also supported by the tests of hypothesized relationships. Configural and weak invariance were supported for all subgroups. Reliability of the SCQ was also supported. CONCLUSIONS Findings indicate the SCQ is a valid and reliable measure of KTx recipients' sexual concerns.
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Mosack V, Hill TJ, Steinke EE. Predictors of change in sexual activity after cardiac diagnosis: Elements to inform sexual counseling. J Health Psychol 2015; 22:925-931. [DOI: 10.1177/1359105315619026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Safely returning to sexual activity after being diagnosed with a cardiac condition is at the core of sexual counseling strategies. To further inform sexual counseling, this study examined changes in sexual activity before and after a cardiac diagnosis. Logistic analysis was used to suggest factors that can contribute to a change in sexual activity among cardiac patients. Reduced frequency in sexual activity after a cardiac diagnosis was influenced by greater sexual concerns and a history of smoking, as well as by education and employment status. These findings suggest that cardiac patients experiencing significant concerns about resuming sexual activity need added support through the mental health system.
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17
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Abstract
Patients with cardiovascular disease and their partners frequently have concerns about sexual intimacy, and sexual counseling is needed across health care settings to ensure that patients receive information to safely resume sexual activity. The purpose of this review is to provide practical, evidence-based approaches to enable health care providers to discuss sexual counseling, illustrated by several case scenarios. Evidence shows that patients expect health care providers to initiate sexual activity discussions, although providers may be hesitant and often rely on patients to ask questions. Although some providers cite lack of knowledge or confidence in their ability to provide sexual counseling, others mention time pressures in the clinical setting. Although such barriers exist, sexual counseling can be individualized to the cardiac condition of a patient with a few select questions. The representative examples of patients with angina pectoris, myocardial infarction, coronary artery bypass surgery, heart failure, and implantable cardioverter defibrillator are used to illustrate key points and provide a model for sexual counseling in practice.
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Mosack V, Hill TJ, Steinke EE. Sexual concerns of cardiac patients: predictors and the influence of specific sexual activities. Eur J Cardiovasc Nurs 2015; 14:45-52. [PMID: 24366982 DOI: 10.1177/1474515113517782] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Addressing sexual concerns of cardiac patients is integral to comprehensive patient-centered nursing care, and instruments for use across cardiac populations are needed to promote this activity. Knowing the factors that contribute to sexual concerns provides insights that help to promote inclusion of assessment of relevant sexual activity and provide sexual counseling as a standard of care. AIM This study examined demographic factors, comorbid conditions, and sexual activities as predictive of sexual concerns. Specific sexual activities and demographic variables were also examined for their relation to sexual concerns. METHODS This study was a sub-analysis of a cross-sectional observational study testing a regression model of factors that predicted sexual concerns in a broad sample of cardiac patients in the United States, using a self-report survey method. RESULTS More comorbidities and types of sexual activities contributed to greater sexual concerns reported by respondents. Sexual activities resulting in overall sexual concerns included hugging/kissing, oral sex, and finger penetration. Non-Whites reported more sexual concerns, sexual fears, and symptoms related to sexual activity. Those who were not working/retired from employment reported significantly more sexual concerns and dysfunction, whereas, those who had a smoking/tobacco use history reported more sexual concerns, symptoms, and dysfunction. CONCLUSION This study underscores that cardiac patients across a variety of diagnoses and comorbidities often experience sexual concerns, fears, symptoms, and dysfunction. The strongest predictors of sexual concerns were the number of cardiac and noncardiac comorbidities, thus illustrating the importance of a thorough assessment of these factors when examining sexual concerns of cardiac patients.
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Affiliation(s)
| | - Twyla J Hill
- Department of Sociology, Wichita State University, USA
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Rosman L, Cahill JM, McCammon SL, Sears SF. Sexual health concerns in patients with cardiovascular disease. Circulation 2014; 129:e313-6. [PMID: 24493810 DOI: 10.1161/circulationaha.113.004846] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lindsey Rosman
- Departments of Psychology (L.R., S.L.M., S.F.S.) and Cardiovascular Sciences (J.M.C., S.F.S.), East Carolina University, Greenville, NC
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20
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Mosack V, Hill TJ, Steinke EE. Sexual concerns of cardiac patients: A psychometric analysis. Int J Nurs Pract 2014; 21:756-63. [DOI: 10.1111/ijn.12291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Victoria Mosack
- School of Nursing; Wichita State University; Wichita Kansas USA
| | - Twyla J Hill
- Department of Sociology; Wichita State University; Wichita Kansas USA
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21
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Erectile dysfunction in the cardiology practice-a patients' perspective. Am Heart J 2014; 167:178-85. [PMID: 24439978 DOI: 10.1016/j.ahj.2013.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 10/28/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Erectile dysfunction (ED) is an independent risk factor for cardiovascular events sharing mutual risk factors with coronary artery disease. Several guidelines for the management of ED in cardiovascular disease have been proposed, recommending cardiologists to routinely inquire about erectile function. However, males' specific needs and wishes regarding sexual health care in cardiology are unknown. We sought to identify male patients' view concerning possible improvements in sexual health care and preferred forms of sexual counseling in the cardiology practice. METHODS This is a cross-sectional multicentered survey study among randomly selected males visiting a cardiologist. RESULTS Of 388 respondents, 296 questionnaires were eligible for analysis. Mean age of respondents was 62.9 years. Overall, 56% (n = 165) had ED, with up to 86% in patients with heart failure. Mean bother experienced due to ED was 5.93 (±2.57) on a 0 to 10 scale. Most respondents indicated to feel comfortable discussing sexual health with the cardiologists (88%). Of men with ED (n = 165), 46% would like to have a conversation with the cardiologist about possibilities to improve sexual function, 55% would be helped if questions could be asked during consultation with a specialized nurse, and 58% would appreciate written information. Of all respondents (n = 296), 28% ever tried a phosphodiesterase inhibitor; 4% received the prescription of the cardiologists. CONCLUSIONS Erectile dysfunction is highly prevalent in patients with a variety of cardiovascular diagnosis and care for sexual function is mandatory. Patients indicated that above consultation with the cardiologist, both consultation with a specialized nurse and written information would be helpful.
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Fluur C, Bolse K, Strömberg A, Thylén I. Spouses' reflections on implantable cardioverter defibrillator treatment with focus on the future and the end-of-life: a qualitative content analysis. J Adv Nurs 2013; 70:1758-69. [PMID: 24321029 DOI: 10.1111/jan.12330] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2013] [Indexed: 12/01/2022]
Abstract
AIM To explore future reflections of spouses living with an implantable cardioverter defibrillator recipient with focus on the end-of-life phase in an anticipated palliative phase. BACKGROUND A history of or risk for life-threatening arrhythmias may require an implantable cardioverter defibrillator. Despite the life-saving capacity of the device, eventually life will come to an end. As discussion about preferences of shock therapy at end-of-life phase seldom takes place in advance, the implantable cardioverter defibrillator recipients may face defibrillating shocks in the final weeks of their lives, adding to stress and anxiety in patients and their families. DESIGN Qualitative study with in-depth interviews analysed with a content analysis. METHODS Interviews were performed with 18 spouses of medically stable implantable cardioverter defibrillator recipients during 2011-2012. RESULTS The spouses described how they dealt with changes in life and an uncertain future following the implantable cardioverter defibrillator implantation. Six subcategories conceptualized the spouses' concerns: Aspiring for involvement; Managing an altered relationship; Being attentive to warning signs; Worries for deterioration in the partner's health; Waiting for the defibrillating shock; and Death is veiled in silence. CONCLUSION Despite the partner's serious state of health; terminal illness or death and the role of the device was seldom discussed with healthcare professionals or the implantable cardioverter defibrillator recipient. Open and honest communication was requested as important to support coping with an unpredictable life situation and to reduce worries and uncertainty about the future and end-of-life.
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Affiliation(s)
- Christina Fluur
- Department of Cardiology UHL, County Council of Östergötland, Linköping, Sweden
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23
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Johansen PP, Zwisler AD, Hastrup-Svendsen J, Frederiksen M, Lindschou J, Winkel P, Gluud C, Giraldi A, Steinke E, Jaarsma T, Berg SK. The CopenHeartSF trial--comprehensive sexual rehabilitation programme for male patients with implantable cardioverter defibrillator or ischaemic heart disease and impaired sexual function: protocol of a randomised clinical trial. BMJ Open 2013; 3:e003967. [PMID: 24282249 PMCID: PMC3845056 DOI: 10.1136/bmjopen-2013-003967] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Sexuality is an important part of people's physical and mental health. Patients with heart disease often suffer from sexual dysfunction. Sexual dysfunction has a negative impact on quality of life and well-being in persons with heart disease, and sexual dysfunction is associated with anxiety and depression. Treatment and care possibilities seem to be lacking. Studies indicate that non-pharmacological interventions such as exercise training and psychoeducation possess the potential of reducing sexual dysfunction in patients with heart disease. The CopenHeartSF trial will investigate the effect of a comprehensive sexual rehabilitation programme versus usual care. METHODS AND ANALYSIS CopenHeartSF is an investigator-initiated randomised clinical superiority trial with blinded outcome assessment, with 1:1 central randomisation to sexual rehabilitation plus usual care versus usual care alone. Based on sample size calculations, 154 male patients with impaired sexual function due to implantable cardioverter defibrillator or ischaemic heart disease will be included from two university hospitals in Denmark. All patients receive usual care and patients allocated to the experimental intervention group follow a 12-week sexual rehabilitation programme consisting of an individualised exercise programme and psychoeducative consultation with a specially trained nurse. The primary outcome is sexual function measured by the International Index of Erectile Function. The secondary outcome measure is psychosocial adjustment to illness by the Psychosocial Adjustment to Illness Scale, sexual domain. A number of explorative analyses will also be conducted. ETHICS AND DISSEMINATION CopenHeartSF is approved by the regional ethics committee (no H-4-2012-168) and the Danish Data Protection Agency (no 2007-58-0015) and is performed in accordance with good clinical practice and the Declaration of Helsinki in its latest form. REGISTRATION Clinicaltrials.gov identifier: NCT01796353.
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Affiliation(s)
- Pernille Palm Johansen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ann-Dorthe Zwisler
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Denmark
| | - Jesper Hastrup-Svendsen
- The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Science, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Frederiksen
- Department of Cardiology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jane Lindschou
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Per Winkel
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Annamaria Giraldi
- Sexological Clinic, Psychiatric Center Copenhagen, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Tiny Jaarsma
- Department of Social and Welfare Studies, Linköping University, Linköping, Sweden
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Steinke EE. Sexuality and chronic illness. J Gerontol Nurs 2013; 39:18-27; quiz 28-9. [PMID: 24066783 DOI: 10.3928/00989134-20130916-01] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/15/2013] [Indexed: 11/20/2022]
Abstract
Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice.
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Steinke EE, Jaarsma T, Barnason SA, Byrne M, Doherty S, Dougherty CM, Fridlund B, Kautz DD, Mårtensson J, Mosack V, Moser DK. Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP). Eur Heart J 2013; 34:3217-35. [PMID: 23900695 DOI: 10.1093/eurheartj/eht270] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.
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Berg SK, Elleman-Jensen L, Zwisler AD, Winkel P, Svendsen JH, Pedersen PU, Moons P. Sexual concerns and practices after ICD implantation: findings of the COPE-ICD rehabilitation trial. Eur J Cardiovasc Nurs 2013; 12:468-74. [DOI: 10.1177/1474515112473528] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Per Winkel
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Denmark
| | | | | | - Philip Moons
- The Heart Centre, University of Copenhagen, Denmark
- Centre for Health Services and Nursing Research, KU Leuven – University of Leuven, Belgium
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Development and testing of an intervention to improve outcomes for partners following receipt of an implantable cardioverter defibrillator in the patient. ANS Adv Nurs Sci 2012; 35:359-77. [PMID: 23107992 DOI: 10.1097/ans.0b013e318271d2e8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The purpose of this article is to describe 3 foundational studies and how their results were used to formulate, design, and test a novel partner intervention for implementation in the immediate post-ICD (implantable cardioverter defibrillator) period after returning home. Nursing's expanding role into chronic illness management in the creation of evidence-based practice is highlighted. A randomized clinical trial comparing 2 intervention programs is being conducted with patients who receive an ICD for the first time and their intimate partners. Primary outcomes are physical functioning, psychological adjustment, relationship impact, and health care utilization.
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Levine GN, Steinke EE, Bakaeen FG, Bozkurt B, Cheitlin MD, Conti JB, Foster E, Jaarsma T, Kloner RA, Lange RA, Lindau ST, Maron BJ, Moser DK, Ohman EM, Seftel AD, Stewart WJ. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2012; 125:1058-72. [PMID: 22267844 DOI: 10.1161/cir.0b013e3182447787] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Goossens E, Norekvål TM, Faerch J, Hody L, Olsen SS, Darmer MR, Jaarsma T, Moons P. Sexual counselling of cardiac patients in Europe: culture matters. Int J Clin Pract 2011; 65:1092-9. [PMID: 21923848 DOI: 10.1111/j.1742-1241.2011.02756.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Sexual problems are common amongst cardiac patients, and concerns may arise when resuming sexual activities after a cardiac event. Sexual counselling is therefore indispensible. Culture is an identified barrier to talking about sex, but research is lacking on whether and how culture influences nurses in providing sexual counselling. DESIGN This cross-sectional descriptive study assessed four areas related to sexual counselling provided by cardiovascular nurses. We investigated the impact of culture on these areas by surveying cardiovascular nurses living in Denmark, Norway and two regions of Belgium - Flanders, Dutch-speaking region and Wallonia, French-speaking region. METHODS Overall, 819 participants were recruited as they attended cardiovascular nursing congresses in Denmark, Norway and Belgium. Subjects completed the Undertaking Nursing Interventions Throughout Europe (UNITE) sexual counselling questionnaire, measuring practice, responsibility, confidence and perceived comfort of patients. Controlling for demographic, educational and professional covariates, we performed multiple linear regression analysis to determine the impact of culture on sexual counselling. RESULTS All four subscale scores were independently associated with culture. Danish nurses counselled patients significantly more often, reported feeling more responsibility and confidence and estimated more comfort in patients than Norwegian, Flemish and Walloon nurses. CONCLUSIONS This study showed that culture matters with respect to sexual counselling for cardiac patients. Interventions should be developed improving sexual counselling of cardiac patients. Educational courses and training of healthcare professionals on sexual counselling should be more sensitive to sociocultural differences. Cross-cultural perspectives may bias attitudes of professionals as they deal with concerns of cardiac patients about resuming sexual activity.
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Affiliation(s)
- E Goossens
- Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Leuven, Belgium
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Palacios-Ceña D, Losa-Iglesias ME, Alvarez-López C, Cachón-Pérez M, Reyes RAR, Salvadores-Fuentes P, Fernández-de-Las-Peñas C. Patients, intimate partners and family experiences of implantable cardioverter defibrillators: qualitative systematic review. J Adv Nurs 2011; 67:2537-50. [PMID: 21615459 DOI: 10.1111/j.1365-2648.2011.05694.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Palacios-Ceña D, Losa ME, Fernández-de-las-Peñas C, Salvadores-Fuentes P. Living with life insurance: a qualitative analysis of the experience of male implantable defibrillator recipients in Spain. J Clin Nurs 2011; 20:2003-13. [DOI: 10.1111/j.1365-2702.2010.03508.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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VAN DEN BROEK KRISTAC, HABIBOVIĆ MIRELA, PEDERSEN SUSANNES. Emotional Distress in Partners of Patients with an Implantable Cardioverter Defibrillator: A Systematic Review and Recommendations for Future Research. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:1442-50. [DOI: 10.1111/j.1540-8159.2010.02885.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
It is increasingly realized that discussing sexuality is an important issue in the holistic care for cardiac patients. In this review article, the conditions of a good assessment of sexual problems are identified such as creating an appropriate environment, ensuring confidentiality, and using appropriate language. Second, we present different styles and approaches that can be used to start the assessment, differing between settings, persons, or disciplines. The PLISSIT (permission, limited information, specific suggestion, and intensive therapy) model can be helpful to initiate discussion about sexuality with the cardiac patient and his/her partner. This model is a stepwise approach using various levels of discussion or treatment. Open-ended question can facilitate discussion about sexual concerns, and validated questionnaires or diaries can be used to assess sexual problems. Patients with sexual concerns and problems should be counseled and/or treated appropriately, and adequate follow-up is needed. Additional training and research are needed to further improve the quality of sexual assessment and counseling in cardiac patients.
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Palacios-Ceña D, Alonso-Blanco C, Cachón-Pérez JM, Alvarez-López C. [The daily experience of the patient with an implantable cardioverter defibrillator]. ENFERMERIA CLINICA 2010; 20:97-104. [PMID: 20199887 DOI: 10.1016/j.enfcli.2009.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Revised: 08/13/2009] [Accepted: 09/29/2009] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Domingo Palacios-Ceña
- Departamento de Ciencias de la Salud II, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, España.
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Sexuality, an important component of the quality of life of the kidney transplant recipient. Transplant Rev (Orlando) 2009; 23:214-23. [DOI: 10.1016/j.trre.2009.06.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Dougherty CM, Thompson EA. Intimate partner physical and mental health after sudden cardiac arrest and receipt of an implantable cardioverter defibrillator. Res Nurs Health 2009; 32:432-42. [PMID: 19434648 DOI: 10.1002/nur.20330] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to describe the physical and mental health of the intimate partners of persons receiving an implantable cardioverter defibrillator (ICD). A prospective longitudinal repeated measures design was used, with data collected at hospital discharge, and at 1, 3, 6, and 12 months after implantation. Intimate partners' physical health, symptoms, and depression significantly declined over the first year. Although anxiety was significantly reduced over time, it remained elevated in partners after 1 year. The impact of implantation of the ICD on the intimate relationship and care demands was most dramatic at hospital discharge. Health care use was low throughout the year. Intimate partners could benefit from an intervention that would assist in their psychological adjustment and provide strategies for dealing with caregiving demands at home.
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Affiliation(s)
- Cynthia M Dougherty
- Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Box 357266, Seattle, WA, USA
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Abstract
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.
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Kuhl EA, Sears SF, Conti JB. Using Computers to Improve the Psychosocial Care of Implantable Cardioverter Defibrillator Recipients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 29:1426-33. [PMID: 17201853 DOI: 10.1111/j.1540-8159.2006.00558.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Person-to-person psychosocial interventions (e.g., psychological, social) enhance the well-being of implantable cardioverter defibrillator (ICD) patients. Computerized care, though, represents an opportunity to further capitalize on techniques that have already been deemed effective. This includes the provision of tailored, effective patient education; reducing device-specific anxiety; and enhancing social support networks. The aim of this paper is to identify the ways in which computerized psychosocial care could potentially enhance the well-being of ICD recipients. For example, computers may be particularly adept at providing patient education due to the ease in which content can be adapted to meet patient needs. Further, evidenced-based treatments for anxiety and depression (e.g., cognitive behavioral therapy) have demonstrated good applicability to computerized formats. Social support can also be provided online in the form of bulletin boards, email list-servs, or structured online support groups. Despite the existence of some limitations, the use of computers in affecting psychosocial outcomes in implantable defibrillator recipients warrants greater attention.
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Affiliation(s)
- Emily A Kuhl
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida 32610, USA.
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Steinke EE, Gill-Hopple K, Valdez D, Wooster M. Sexual concerns and educational needs after an implantable cardioverter defibrillator. Heart Lung 2005; 34:299-308. [PMID: 16157184 DOI: 10.1016/j.hrtlng.2005.03.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 02/28/2005] [Accepted: 03/04/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with an implantable cardioverter defibrillator (ICD) describe anxiety, fears, and other psychosocial issues, although sexual concerns are not well understood. PURPOSE The purpose of this descriptive study was to explore the experiences of patients and partners with return to sexual activity post-ICD implantation. PARTICIPANTS Subjects were 12 patients with an ICD (10 men, 2 women) and 4 partners (1 man, 3 women). Most patients with an ICD and partners were age 55 years or older, with a mean age of 62 years for patients and 47 years for partners. METHODS A semistructured interview was used to explore the meaning and influence of the ICD on the sexual relationship. Interviews were recorded, transcribed verbatim, and analyzed using a qualitative descriptive approach. RESULTS Themes identified were (1) anxiety and apprehension, with subthemes of partner overprotectiveness and fear of ICD discharge with sexual activity; (2) varying interest and pattern of sexual activity; (3) powerfulness of ICD discharge; and (4) a need for information and sexual counseling. IMPLICATIONS Additional research is needed to further understand the experience of ICD discharge with sexual activity and to develop educational strategies.
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Affiliation(s)
- Elaine E Steinke
- Wichita State University, School of Nursing, Wichita, Kansas 67260, USA
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Abstract
Use of implantable cardioverter defibrillators has become standard therapy for patients at high risk for life-threatening ventricular arrhythmias. Although acceptance of the device is generally high among patients and their families, quality of life and psychosocial issues associated with use of the defibrillators deserve greater attention to improve outcomes. Psychosocial issues, their ramifications, and theory-and evidence-based approaches to improving outcomes are described.
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Affiliation(s)
- Sandra B. Dunbar
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
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Steinke EE. INTIMACY NEEDS AND CHRONIC ILLNESS: Strategies for Sexual Counseling and Self-Management. J Gerontol Nurs 2005; 31:40-50. [PMID: 15916202 DOI: 10.3928/0098-9134-20050501-08] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Individuals experiencing a chronic illness have many needs and concerns. One area frequently overlooked is that of intimacy. Those experiencing cardiovascular illnesses have concerns about the strain of sexual activity on their heart. Individuals with lung diseases may perceive that sexual activity is no longer possible because of breathing difficulties. Accurate information and strategies for self-management are needed to address the intimacy needs and concerns of these individuals. The purpose of this article is to identify intimacy needs and strategies for sexual counseling for individuals with cardiovascular illnesses such as myocardial infarction, heart failure, implantable defibrillators, hypertension, and for chronic lung problems.
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Affiliation(s)
- Elaine E Steinke
- School of Nursing, Wichita State University, Kansas 67260-0041, USA
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