Health-Related Quality of Life Consequences of Implantable Cardioverter Defibrillators

The effect of right ventricle septal pacing versus apical pacing in dual-chamber pacemakers on patients' anxiety and depression: a one-year follow-up study

BACKGROUND

Anxiety and depression are potentially harmful outcomes of permanent cardiac pacemakers. Dual-chamber P.P.M. is frequently used to treat life threatening bradycardia. The study aims to estimate the effect of the right ventricular PM lead position on recipients' anxiety and depression before, 6 months, and 1 year after implantation.

RESULTS

A statistically significant correlation was discovered between the studied groups regarding HADS depression score after 6 months (p 0.013) and 1 year (p 0.013). A statistically non-significant difference was found among the studied groups at any point of time regarding baseline (p 0.063), after 6 months (p 0.054), or after 1 year (p 0.099). Significance was found between HADS anxiety score (p 0.015) or depression score after 1 year and the incidence of complications (p 0.001).

CONCLUSIONS

A strong relationship was found between the level of depression and the R.V. site of implantation, as patients with the apical group had higher levels of depression post-implantation. The septal position has less stress and depression on the patient's well-being than the apical one.

Assessment of the Impact of Cardiac Implantable Electronic Devices on Patients' Quality of Life

INTRODUCTION

Assessing the quality of life serves as a crucial metric during various therapeutic or surgical procedures. The rise in cardiac electronic device implantations in recent years underscores the significance of evaluating the quality of life among such patients.

MATERIALS AND METHODS

We conducted a study focusing on the quality of life of 438 patients with cardiac implantable electronic devices (cardiac pacemakers, cardioverter-defibrillators, cardiac resynchronization therapy devices). These patients were diagnosed with sick sinus syndrome, high-degree atrioventricular (AV) block, or severe heart failure (New York Heart Association (NYHA) classes III- IV (NYHA III-IV)), with left ventricular ejection fraction (LVEF) ≤ 35%, with/without complete left bundle branch block (QRS ≥ 130 μs), or with a history of ventricular tachycardia/ventricular fibrillation. The study utilized the EuroQol 5-Dimension 5-level (EQ-5D-5L) questionnaire and the EQ visual analog scale, which patients completed both prior to cardiac device implantation and during six post-implantation follow-up visits. The analysis of the research findings was conducted using the IBM SPSS Statistics software program (Armonk, NY).

RESULTS

Cardiac pacemaker implantation in patients with sick sinus syndrome and high-grade AV block demonstrated significant and highly reliable positive effects on quality of life concerning mobility, self-care, and usual activity. Similarly, cardiac resynchronization device implantation in individuals with severe heart failure with reduced LVEF and wide QRS showed significant positive effects in these areas. However, cardioverter-defibrillator implantation did not yield positive effects on these modules. Regarding pain/discomfort, neither pacemaker nor cardiac resynchronization device implantation resulted in improved quality of life, while there was a somewhat positive effect observed in the cardioverter-defibrillator group. In terms of anxiety/depression, pacemaker implantation in patients with sick sinus syndrome and high-degree AV block had a significant and highly reliable positive impact on quality of life. Additionally, relatively positive impacts were noted at various periods following cardioverter-defibrillator and cardiac resynchronization device implantations.

CONCLUSIONS

Cardiac implantable electronic devices play a crucial role not only in saving lives but also in positively impacting the quality of life of patients when appropriately selected.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Health-Related Quality of Life in the Spironolactone to Reduce ICD Therapy (SPIRIT) Trial

To describe health related quality of life (HRQOL) and symptoms in the SPIRIT trial and determine effects of implantable cardioverter defibrillator (ICD) shocks on HRQOL over 24 months. Ninety participants aged 66 ± 10 years, 96% men, 75% with NYHA class II, with an ICD were randomized to spironolactone 25 mg (N = 44) or placebo (N = 46). HRQOL was measured every 6 months for 24 months using: Patient Concerns Assessment (PCA), Short Form Health Survey-Veterans Version (SF-36V), and Kansas City Cardiomyopathy Questionnaire (KCCQ). Linear mixed modeling compared changes in HRQOL over-time and ANCOVA compared HRQOL between those getting an ICD shock or not. Over 24-months, there were no differences in HRQOL between the spironolactone versus placebo groups. Those with at least one ICD shock reported significantly lower HRQOL and more symptoms at 6- and 24-months. Patients receiving one or more ICD shocks reported significant reductions in HRQOL and higher symptoms.

Comparative Study between Subcutaneous and Endovascular Defibrillator Recipients Regarding Tolerance to the Implant Procedure and Perception of Quality of Life

BACKGROUND

The totally subcutaneous implantable cardioverter-defibrillator (S-ICD) is a safe alternative to the conventional transvenous ICD (TV-ICD) system to prevent sudden death.

OBJECTIVE

To compare the impact of the type of ICD system and surgical technique on patients' quality of life, as well as the severity of discomfort and pain, between S-ICD and TV-ICD recipients.

METHODS

Consecutively implanted patients with an S-ICD system were matched with patients with a TV-ICD system. In addition, patients undergoing S-ICD implantation after removal of a TV-ICD due to complications were included. Quality of life (measured with the 12-item short-form health survey) and severity of pain and discomfort were evaluated. Statistical significance was defined as p < 0.05.

RESULTS

A total of 64 patients implanted with S-ICD or TV-ICD under local anesthesia and conscious sedation were analyzed. Patients with S-ICD and TV-ICD systems did not differ significantly in quality of life scores. S-ICD patients had a higher level of perioperative pain; no differences were found regarding severity of intraoperative pain. The magnitude of aesthetic discomfort and sleep disturbances did not differ between groups. An S-ICD was implanted in 7 additional patients after removal of a TV-ICD. All but one of these patients recommended the S-ICD system.

CONCLUSIONS

The type of ICD system and the surgical technique have negligible impact on patients' quality of life. These results suggest that conscious sedation, provided by an experienced electrophysiology team, could be considered as an alternative to general anesthesia to manage patients undergoing S-ICD implantation.

The impact of implantable cardioverter-defibrillator implantation on health-related quality of life in the DANISH trial

AIM

The Danish Study to Assess the Efficacy of Implantable Cardioverter-Defibrillators (ICD) in Patients with Non-ischaemic Systolic Heart Failure (HF) on Mortality (DANISH) found no overall effect on all-cause mortality. The effect of ICD implantation on health-related quality of life (HRQoL) remains to be established as previous trials have demonstrated conflicting results. We investigated the impact of ICD implantation on HRQoL in patients with non-ischaemic systolic HF, a prespecified secondary endpoint in DANISH.

METHODS AND RESULTS

In DANISH, a total of 1116 patients with non-ischaemic systolic HF were randomly assigned (1:1) to ICD implantation or usual clinical care (control). Patients completed disease-specific HRQoL as assessed by Minnesota Living with Heart Failure Questionnaire (MLHFQ; 0-105, high indicating worse). Changes in HRQoL 8 months after randomization were assessed with a mixed-effects model. At randomization, MLHFQ was completed by 935 (84%) patients (n = 472 in the ICD group and n = 463 in the control group) and was reassessed in 274 (58%) and 292 (63%) patients, respectively after 8 months for the primary analysis. Patients in the ICD group vs. the control group had similar improvements in MLHFQ after 8 months [least square mean -7.0 vs. -4.2 (P = 0.13)]. A clinically relevant improvement (decrease ≥5) in the MLHFQ overall score at 8 months was observed in 151 patients in the ICD group and 148 patients in the control group [55% vs. 51%, respectively (P = 0.25)].

CONCLUSION

Implantable cardioverter-defibrillator implantation in patients with non-ischaemic systolic HF did not significantly alter HRQoL compared with patients randomized to usual clinical care.

Shared decision-making for ICDs: a regional collaborative initiative

The National Institute for Health and Care Excellence (NICE) and NHS England have shown a commitment to embedding shared decision-making (SDM) in clinical practice and developing decision aids based on clinical guidelines. Healthcare policy makers are keen to enhance the engagement of patients in SDM in the belief that it improves the benefits accrued from healthcare interventions. This may be important for interventions such as implantable cardioverter-defibrillator (ICD) implantation, where cost-effectiveness is under scrutiny. NHS England invited the ICD implanters in the north of England to participate in a regional commissioning quality incentive (CQUIN) project to improve decision- making around a primary prevention ICD implant. A collaborative project included the development of a specific SDM tool, the first of its kind in the UK, followed by training and education of the clinical teams. The project illustrates that this approach is practical and deliverable and could be applied and used in other regions, and considered in additional clinical areas.

Morbidity and mortality with cardiac resynchronization therapy with pacing vs. with defibrillation in octogenarian patients in a real-world setting

Aims

Cardiac resynchronization therapy (CRT) with a defibrillator (CRT-D) has downsides of high cost and inappropriate shocks compared to CRT without a defibrillator (CRT-P). Recent data suggest that the survival benefit of implantable cardioverter defibrillator (ICD) therapy is attenuated in the older age group. We hypothesized that, among octogenarians eligible for cardiac resynchronization therapy, CRT-P confers similar morbidity and mortality benefits as CRT-D.

Methods and results

We compared morbidity and mortality outcomes between consecutive octogenarian patients eligible for CRT therapy who underwent CRT-P implantation at Barzilai MC (n = 142) vs. those implanted with CRT-D for primary prevention indication who were prospectively enrolled in the Israeli ICD Registry (n = 104). Among the 246 study patients, mean age was 84 ± 3 years, 74% were males, and 66% had ischaemic cardiomyopathy. Kaplan-Meier survival analysis showed that at 5 years of follow-up the rate of all-cause mortality was 43% in CRT-P vs. 57% in the CRT-D group [log-rank P = 0.13; adjusted hazard ratio (HR) = 0.79, 95% CI 0.46-1.35, P = 0.37]. Kaplan-Meier analysis also showed no significant difference in the rates of the combined endpoint of heart failure or death (46 vs. 60%, respectively, log-rank P = 0.36; adjusted HR was 0.85, 95% CI 0.51-1.44, P = 0.55). A Cox proportional hazard with competing risk model showed that re-hospitalizations for cardiac cause were not different for the two groups (adjusted HR 1.35, 95% CI 0.7-2.6, P = 0.37).

Conclusion

Our data suggest that, in octogenarians with systolic heart failure, CRT-P therapy is associated with similar morbidity and mortality outcomes as CRT-D therapy.

Quality of life in patients with implantable cardioverter–defibrillator: systematic review of randomized controlled trials

Background:

Implantable cardioverter–defibrillator (ICD) therapy significantly improves the survival of patients who are at high risk for sudden cardiac death. However, it is unclear whether this survival is accompanied by impairment on quality of life (QoL).

Objectives:

This systematic review sought to describe whether ICD therapy, as compared with standard treatment, can have an impact on QoL outcomes.

Methods:

Extensive literature searches were carried out in PubMed, EMBASE, LILACS and Cochrane Library. Eligible studies were randomized controlled trials (RCTs) of ICD versus medical therapy that reported valid and reliable measures of QoL. Included studies were reviewed to determine baseline patient characteristics, mean duration of follow-up, questionnaires used to assess QoL and association between QoL scores and ICD shock therapy.

Results:

Seven studies, enrolling a total of 5,701 patients, were included in this review. The analyzed trials showed conflicting results about the impact of ICD on QoL outcomes. Among the secondary prevention studies, CIDS reported a clear benefit from ICD and AVID showed no difference between ICD and amiodarone groups. Of the primary prevention trials, AMIOVIRT, MADIT II, DEFINITE, and SCD-HeFT found no evidence of impaired QoL in patients with an ICD. Evidence for an association between ICD shocks and QoL was mixed and seemed to depend on the interval between shocks and QoL assessment.

Conclusion:

There was no evidence of impaired QoL in patients with an ICD. However, ICD patients must be educated of all possible risks and benefits, including transitory declines in QoL after ICD shocks.

[Sexual activity in implantable cardioverter defibrillator patients included in cardiac rehabilitation]

OBJECTIVES

To analyse the effects of a Cardiac Rehabilitation Program (CRP) on quality of life and sexual activity levels in patients with implantable cardioverter defibrillators (ICD).

METHOD

A total of 25 patients (22 men and 3 women) were included in a study that consisted of the analysis of any defibrillator discharges, their repercussion on the couple, and the effects of CRP on physical and psychological aspects, and on sexual activity (SA).

RESULTS

The mean age of the patients was 55years (22 to 79). Initially, fear for device discharges was present in all patients. On arrival, 14 patients (56%) did not have any SA: 2 with ages of 69 and 79years; one woman due to severe anxiety; an alcoholic man, and 10 because the ICD had been implanted less than 1 month before. Nine men and two women had restarted SA: 5 of them 5-52months after the implantation, and the other 6, 30days after implantation of the ICD while attending the CRP. At the end of the study, 21 patients had regained SA. Two men had clinical signs of depression and anxiety, with one requiring specialised treatment. Functional capacity improved significantly, 6.5±3.0METs at the beginning of the program and 9.2±3.3METs at the end, with a P<.005. There was only one inappropriate discharge.

CONCLUSIONS

Discharges caused by newest devices have dropped significantly. This fact, together with the action of CRP at physical, psychological, and informative levels, makes it possible to control the dysfunctions in the quality of life and sexuality in patients.

A feasibility study of arrhythmia risk prediction in patients with myocardial infarction and preserved ejection fraction

AIM

To predict arrhythmia susceptibility in myocardial infarction (MI) patients with left ventricular ejection fraction (LVEF)  >35% using a personalized virtual heart simulation approach.

METHODS AND RESULTS

A total of four contrast enhanced magnetic resonance imaging (MRI) datasets of patient hearts with MI and average LVEF of 44.0 ± 2.6% were used in this study. Because of the preserved LVEF, the patients were not indicated for implantable cardioverter defibrillator (ICD) insertion. One patient had spontaneous ventricular tachycardia (VT) prior to the MRI scan; the others had no arrhythmic events. Simulations of arrhythmia susceptibility were blind to clinical outcome. Models were constructed from patient MRI images segmented to identify myocardium, grey zone, and scar based on pixel intensity. Grey zone was modelled as having altered electrophysiology. Programmed electrical stimulation (PES) was performed to assess VT inducibility from 19 bi-ventricular sites in each heart model. Simulations successfully predicted arrhythmia risk in all four patients. For the patient with arrhythmic event, in-silico PES resulted in VT induction. Simulations correctly predicted that VT was non-inducible for the three patients with no recorded VT events.

CONCLUSIONS

Results demonstrate that the personalized virtual heart simulation approach may provide a novel risk stratification modality to non-invasively and effectively identify patients with LVEF  >35% who could benefit from ICD implantation.

Patient-centred care of patients with ventricular arrhythmias and risk of sudden cardiac death: What do the 2015 European Society of Cardiology guidelines add?

Nurses and allied professionals are at the forefront of care delivery in patients with arrythmogenic risk and have a responsibility to deliver care that is focused on their individual needs. The 2015 European Society of Cardiology guideline on prevention of ventricular arrhythmia and sudden cardiac death heralds a step-change in patient and family focus and interdisciplinary involvement. This development reflects a recognition within the European Society of Cardiology that chronic care of patients with cardiovascular conditions can be improved by involving all stakeholders, making use of multidisciplinary interventions, and placing the patient at the centre of the care process. In this article, taskforce contributors discuss the latest evidence and highlight some of the most pertinent issues for nurses involved in patient-centred care of patients and families with ventricular arrhythmias and/or risk of sudden death.

Quality of Life in Patients with an Implantable Cardioverter Defibrillator: A Systematic Review

Despite the indisputable mortality advantages of implantable cardioverter defibrillators (ICDs), no consensus exists regarding their impact on quality of life (QoL). This systematic review investigates differences in QoL between patients with ICDs and controls. We systematically searched the MEDLINE, EMBASE, Cochrane, Web of Science, and PsychINFO databases. Articles were included if they were published after the year 2000 and reported on original studies with a control group. Five randomized controlled trials with a total of 5,138 patients and 10 observational studies with a total of 1,513 patients met the inclusion criteria. Nine studies found comparable QoL for ICD recipients and patients in the control groups, three studies found an increased QoL for ICD patients, and three studies found a decreased QoL for ICD patients. The question of whether QoL relates to ICD therapy cannot be answered conclusively due to the heterogeneity of the existing studies. Lower QoL was apparent among patients with an ICD who experienced several device discharges. Medical staff should be particularly aware of the signs of both psychological and physical disorders in these patients. Further investigations on QoL in ICD patients are desirable, but ethical reasons restrict the conduct of randomized trials.

Economic evaluations of implantable cardioverter defibrillators: a systematic review

The aim of this paper was to review the cost-effectiveness studies of implantable cardioverter defibrillators (ICD) for primary or secondary prevention of sudden cardiac death (SCD). A systematic review of the literature published in English or Spanish was performed by electronically searching MEDLINE and MEDLINE in process, EMBASE, NHS-EED, and EconLit. Some keywords were implantable cardioverter defibrillator, heart failure, heart arrest, myocardial infarction, arrhythmias, syncope, sudden death. Selection criteria were the following: (1) full economic evaluations published after 1995, model-based studies or alongside clinical trials (2) that explored the cost-effectiveness of ICD with or without associated treatment compared with placebo or best medical treatment, (3) in adult patients for primary or secondary prevention of SCD because of ventricular arrhythmias. Studies that fulfilled these criteria were reviewed and data were extracted by two reviewers. The methodological quality of the studies was assessed and a narrative synthesis was prepared. In total, 24 studies were included: seven studies on secondary prevention and 18 studies on primary prevention. Seven studies were performed in Europe. For secondary prevention, the results showed that the ICD is considered cost-effective in patients with more risk. For primary prevention, the cost-effectiveness of ICD has been widely studied, but uncertainty about its cost-effectiveness remains. The cost-effectiveness ratios vary between studies depending on the patient characteristics, methodology, perspective, and national settings. Among the European studies, the conclusions are varied, where the ICD is considered cost-effective or not dependent on the study.

Implantable cardioverter defibrillators for the treatment of arrhythmias and cardiac resynchronisation therapy for the treatment of heart failure: systematic review and economic evaluation

BACKGROUND

This assessment updates and expands on two previous technology assessments that evaluated implantable cardioverter defibrillators (ICDs) for arrhythmias and cardiac resynchronisation therapy (CRT) for heart failure (HF).

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of ICDs in addition to optimal pharmacological therapy (OPT) for people at increased risk of sudden cardiac death (SCD) as a result of ventricular arrhythmias despite receiving OPT; to assess CRT with or without a defibrillator (CRT-D or CRT-P) in addition to OPT for people with HF as a result of left ventricular systolic dysfunction (LVSD) and cardiac dyssynchrony despite receiving OPT; and to assess CRT-D in addition to OPT for people with both conditions.

DATA SOURCES

Electronic resources including MEDLINE, EMBASE and The Cochrane Library were searched from inception to November 2012. Additional studies were sought from reference lists, clinical experts and manufacturers' submissions to the National Institute for Health and Care Excellence.

REVIEW METHODS

Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Data were synthesised through narrative review and meta-analyses. For the three populations above, randomised controlled trials (RCTs) comparing (1) ICD with standard therapy, (2) CRT-P or CRT-D with each other or with OPT and (3) CRT-D with OPT, CRT-P or ICD were eligible. Outcomes included mortality, adverse events and quality of life. A previously developed Markov model was adapted to estimate the cost-effectiveness of OPT, ICDs, CRT-P and CRT-D in the three populations by simulating disease progression calculated at 4-weekly cycles over a lifetime horizon.

RESULTS

A total of 4556 references were identified, of which 26 RCTs were included in the review: 13 compared ICD with medical therapy, four compared CRT-P/CRT-D with OPT and nine compared CRT-D with ICD. ICDs reduced all-cause mortality in people at increased risk of SCD, defined in trials as those with previous ventricular arrhythmias/cardiac arrest, myocardial infarction (MI) > 3 weeks previously, non-ischaemic cardiomyopathy (depending on data included) or ischaemic/non-ischaemic HF and left ventricular ejection fraction ≤ 35%. There was no benefit in people scheduled for coronary artery bypass graft. A reduction in SCD but not all-cause mortality was found in people with recent MI. Incremental cost-effectiveness ratios (ICERs) ranged from £14,231 per quality-adjusted life-year (QALY) to £29,756 per QALY for the scenarios modelled. CRT-P and CRT-D reduced mortality and HF hospitalisations, and improved other outcomes, in people with HF as a result of LVSD and cardiac dyssynchrony when compared with OPT. The rate of SCD was lower with CRT-D than with CRT-P but other outcomes were similar. CRT-P and CRT-D compared with OPT produced ICERs of £27,584 per QALY and £27,899 per QALY respectively. The ICER for CRT-D compared with CRT-P was £28,420 per QALY. In people with both conditions, CRT-D reduced the risk of all-cause mortality and HF hospitalisation, and improved other outcomes, compared with ICDs. Complications were more common with CRT-D. Initial management with OPT alone was most cost-effective (ICER £2824 per QALY compared with ICD) when health-related quality of life was kept constant over time. Costs and QALYs for CRT-D and CRT-P were similar. The ICER for CRT-D compared with ICD was £27,195 per QALY and that for CRT-D compared with OPT was £35,193 per QALY.

LIMITATIONS

Limitations of the model include the structural assumptions made about disease progression and treatment provision, the extrapolation of trial survival estimates over time and the assumptions made around parameter values when evidence was not available for specific patient groups.

CONCLUSIONS

In people at risk of SCD as a result of ventricular arrhythmias and in those with HF as a result of LVSD and cardiac dyssynchrony, the interventions modelled produced ICERs of < £30,000 per QALY gained. In people with both conditions, the ICER for CRT-D compared with ICD, but not CRT-D compared with OPT, was < £30,000 per QALY, and the costs and QALYs for CRT-D and CRT-P were similar. A RCT comparing CRT-D and CRT-P in people with HF as a result of LVSD and cardiac dyssynchrony is required, for both those with and those without an ICD indication. A RCT is also needed into the benefits of ICD in non-ischaemic cardiomyopathy in the absence of dyssynchrony.

STUDY REGISTRATION

This study is registered as PROSPERO number CRD42012002062.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Implantable cardioverter-defibrillators in the elderly: rationale and specific age-related considerations

Despite the increasingly high rate of implantation of cardioverter-defibrillators (ICD) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We comprehensively reviewed the state-of-the-art data regarding the applicability, safety, clinical- and cost-effectiveness of the ICD in elderly patients, and analysed which patients in this age stratum are more likely to get a survival benefit from this therapy. Although peri-procedural risk may be slightly higher in the elderly, this procedure is still relatively safe in this age group. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is comparable in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantage of the device on arrhythmic death may be largely attenuated by a higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in highly selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD intervention among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live >5-7 years after implantation. Biological age rather than chronological age per se should be the decisive factor in making a decision on ICD selection for survival benefit.

Interaction between cardioverter defibrillator and enhanced external counterpulsation device

BACKGROUND

Potential interference between implanted cardiac devices and other medical instruments is an important concern. Therefore, we aimed to investigate the possible device interaction between implantable cardioverter defibrillators (ICDs) and external enhanced counterpulsation (EECP) treatment.

METHODS

Twenty-one patients with an implanted ICD or cardiac resynchronization therapy with defibrillator (CRT-D) were enrolled into the study. EECP had applied as two sessions of 5 minutes. Data from device interrogations before and after the first EECP session and during second EECP session were recorded and analyzed for signs of possible device interaction.

RESULTS

There was no sign of inappropriate sensing or noise during EECP session. There was no difference regarding electrode impedance, pacing, and sensing values before and after EECP. There was a statistically significant difference regarding heart rates during EECP therapy between rate response off and on modes (68.69 ± 5.92 beats/min and 90.32 ± 11.05 beats/min, respectively P = 0,001). In four patients with CRT-D and unipolar left ventricular pacing, counterpulsation could not be done because of QRS sensing problems.

CONCLUSIONS

EECP seems to be a safe treatment modality in patients with implanted ICD and CRT-D devices. It should be kept in mind that in those patients with CRT-D, rate responsive mode is on; inappropriate sinus tachycardia can be seen during EECP therapy. Also in patients with CRT-D using a unipolar sensing mode, problems of QRS complex sensing by the EECP may occur and, therefore, this effects synchronization and success of EECP therapy.

Patient and cardiologist perceptions on decision making for implantable cardioverter-defibrillators: a qualitative study

BACKGROUND

Although implantable cardioverter-defibrillators (ICDs) reduce mortality in selected patients, they are also associated with potential risks. Periprocedural decision making requires understanding both benefits and risks.

METHODS

This qualitative study aims to understand cardiologists' and patients' perspectives about decision making surrounding ICD implantation using semi-structured, in-depth interviews. We interviewed 11 cardiologists (including four electrophysiologists) and 20 patients (14 with ICDs; six who declined ICDs). The data were analyzed through the theoretical lens of patient-centered care using the constant comparative method.

RESULTS

Cardiologists emphasized the benefits of ICD therapy but varied substantially in the extent to which they emphasized the various risks associated with ICD implantation with patients. Cardiologists indicated that they were influenced by the benefits of therapy as presented in published guidelines. Many patients who chose to receive an ICD indicated that they followed the advice of their physician without questioning the risks and benefits of the device. Some ICD recipients described not learning many of the risks until after device implantation or when they experienced these side effects. Patients who declined ICD implantation were concerned that the ICD was unnecessary or believed that the risks related to sudden death without an ICD did not apply to them. Only one patient considered the trade-off between dying quickly versus living longer with progressive heart failure.

CONCLUSIONS

In our sample, cardiologists' desire to adhere to published guidelines appears to inhibit shared decision making. The marked variability in the discussions surrounding ICD decisions highlights a need for an improved process of ICD decision making.

Cost-effectiveness of implantable defibrillators after myocardial infarction based on 8-year follow-up data (MADIT II)

OBJECTIVES

About 190,000 Germans experience a myocardial infarction each year. Of these, 25% may be eligible for an implantable cardioverter defibrillator (ICD) due to low left ventricular ejection fraction. Given the high costs of implantation, the purpose of this study was to assess the cost-effectiveness of ICDs compared to conventional therapy in patients with an ejection fraction 30% or less after MI in Germany.

METHODS

The economic evaluation was performed from the perspective of the German statutory health insurance. To simulate costs and effectiveness over lifetime, a Markov model was constructed with seven health states. The model was based on 8-year follow-up data for ICD implantation after myocardial infarction (MADIT II), which was published recently.

RESULTS

The analysis shows that ICD implantation compared to conventional therapy in patients fulfilling MADIT-II criteria has a cost-effectiveness ratio of €44,736 per quality-adjusted life year gained. If every patient insured by the statutory health insurance and fulfilling the MADIT-II criteria would receive an ICD, the model suggests expenditures between €173 million and €1.7 billion per year.

CONCLUSIONS

ICD therapy cannot be considered clearly cost-effective when compared to many well-accepted interventions. If policy makers decide to reimburse ICDs in the MADIT-II population, they will need to either raise premiums or abandon coverage for other currently funded medical interventions.

Regional variation in the use of implantable cardioverter-defibrillators for primary prevention: results from the National Cardiovascular Data Registry

BACKGROUND

Although the use of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death varies by sex, race, and hospital, geographic variation in ICD use remains unexplored. Our objective was to quantify regional variations in the utilization of primary prevention ICDs in the United States, and to evaluate if an association exists between utilization and physician supply or the proportion of patients meeting the trial inclusion criteria.

METHODS AND RESULTS

This is a cross-sectional analysis among the Medicare, fee-for-service population from the National Cardiovascular Data Registry. Using hospital referral regions, we calculated the age-, sex-, and race-adjusted rates of ICD placement for each region and assessed the correlation between these rates and (1) physician supply and (2) the proportion of patients meeting trial inclusion criteria. Substantial variation was found across quintiles of rate ratios of ICD implantation, ranging from 0.39 to 1.77 (compared with a national mean rate of 1.0). This ratio was not correlated with the supply of cardiologists (R(2)=0.01), electrophysiologists (R(2)=0.01), or with the proportion of patients meeting trial inclusion criteria (R(2)<0.01). Over all, 13% of all patients receiving ICDs did not meet trial criteria.

CONCLUSIONS

Marked geographic variation in the use of primary prevention ICDs exists across the United States that is not correlated with physician supply. Although >1 in 10 patients received ICDs outside of trial criteria, this potential overuse did not explain the variation. Future studies should consider underuse or misuse of primary prevention ICDs as causes of geographic variation.

Cost-effectiveness of implantable cardioverter defibrillators in patients >or=65 years of age

BACKGROUND

More than 80% of sudden cardiac deaths (SCDs) occur in patients >or=65 years old; the cost-effectiveness of implantable cardioverter defibrillator (ICD) therapy in older patients remains unclear. We sought to examine the cost-effectiveness of ICD therapy in at-risk patients >or=65 years old.

METHODS

We developed a Markov model to evaluate lifetime costs and benefits of ICD therapy compared with optimal medical therapy in patients >or=65 years of age with left ventricular dysfunction. Data were derived from the literature and existing clinical trials of primary prevention of SCD. Outcome measures included life years, quality-adjusted life years, costs, and incremental cost-effectiveness.

RESULTS

Benefits and costs of ICD therapy in older individuals varied widely by clinical-trial population. In the 5 trials considered, for patients >or=65 years of age, ICDs demonstrated a life expectancy benefit compared with control therapy (incremental cost-effectiveness ratios ranging from $37,031-$138,458 per quality-adjusted life year). For 75-year-old patients, the findings were qualitatively similar, although cost-effectiveness was reduced in all trial populations. In sensitivity analyses, cost-effectiveness of ICD therapy in older individuals depended upon the trial population, quality of life, device cost, and frequency of generator replacement. Sensitivity analyses on other variables did not change the results substantially.

CONCLUSIONS

The cost-effectiveness of ICD therapy for primary prevention in older patients varies widely among trials. Given an aging US population and the high risk of SCD in these individuals, further studies of ICD therapy and their cost-effectiveness-specifically in older patients-are needed.

Cost-effectiveness of implantable cardioverter-defibrillators in children with dilated cardiomyopathy

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) improve survival and are cost-effective in adults with poor left ventricular function. Because of differences in heart failure etiology, sudden death rates, and ICD complication rates, these findings may not be applicable to children.

METHODS AND RESULTS

We developed a Markov model to compare typical management of childhood dilated cardiomyopathy with symptomatic heart failure to prophylactic ICD implantation plus typical management. Model costs included costs of outpatient care, medications, complications, and transplantation. Time horizon was up to 20 years from model entry. Total costs were $433,000 (ICD strategy) and $355,000 (typical management). Although quality adjusted survival was greater in the ICD group (6.78 versus 6.43 quality adjusted life-years [QALY]), the incremental cost-utility ratio was $281,622/QALY saved with the ICD strategy. In sensitivity analyses, the ICD strategy cost less than the $100,000/QALY benchmark for cost-effectiveness only when the annual probability of sudden death exceeded 13% or when strong, sustained benefits in quality of life from the ICD were assumed.

CONCLUSIONS

Prophylactic ICD use in children with dilated cardiomyopathy, poor ventricular function, and symptomatic heart failure does not appear to be cost-effective. This is likely due to lower sudden death rates in this population.

Examination of the effect of implantable cardioverter-defibrillators on health-related quality of life: based on results from the Multicenter Automatic Defibrillator Trial-II

While implantable cardioverter-defibrillators (ICDs) improve survival, their benefit in terms of health-related quality of life (HRQOL) is negligible. To examine how shocks and congestive heart failure (CHF) mediate the effect of ICDs on HRQOL. The US patients from the MADIT-II (Multicenter Automatic Defibrillator Trial-II) trial (n = 983) were randomized to receive an ICD or medical treatment only. HRQOL was assessed using the Health Utility Index 3 at baseline and 3, 12, 24, and 36 months following randomization. Logistic regressions were used to test for the effect of ICDs on the CHF indicator, and linear regressions were used to examine the effect of ICD shocks and CHF on HRQOL in living patients. We used a Monte Carlo simulation and a parametric Weibull distribution survival model to test for the effect of selective attrition. Observations were clustered by patients and robust standard errors (RSEs) were used to control for the non-independence of multiple observations provided by the same patient. Patients in the ICD arm had 41% higher odds of experiencing CHF since their last assessment compared with those in the control arm (RSE = 0.19, p = 0.01). Developing CHF reduced HRQOL at the subsequent visit by 0.07 (p < 0.01). Having ICD shocks reduced overall HRQOL by 0.04 (p = 0.04) at the subsequent assessment. The negative effect of ICD firing on HRQOL was an order of magnitude greater than the effect of CHF. A higher prevalence of CHF and shocks among patients with ICDs and their negative effect on HRQOL may partially explain the lack of HRQOL benefit of ICD therapy.

[Quality of life analysis in patients with an implantable cardioverter-defibrillator]

OBJECTIVES

To describe possible changes in the quality of life (QL) and to identify possible differences associated to sociodemographic and clinical variables after being given an implantable cardioverter-defibrillator (ICD).

METHOD

Descriptive cross-sectional study, selecting 241 consecutive patients for a subcutaneous or subpectoral ICD implantation. One-hundred and fifty-seven patients met inclusion criteria. Introduction letter along with the assessment tool was mailed to them. Assessment tool used was the Euroqol-5D (EQ5D), validated and translated for a Spanish population. EQ5D describes health status in 5 domains: mobility (MO), self-care (SC), usual activity (UA), pain/discomfort (PD) and anxiety/depression (AD). It included a visual analogue scale (VAS) where the endpoints are labelled 'Best imaginable health state' and 'Worst imaginable health state'; one before and another after ICD implantation.

RESULTS

Ninety valid assessments were received: 80 males, mean age 61.2+/-13.1 years. Patients with EQ5D problems: MO 25 (27.7%), SC 8 (8.8%), UA 32 (35.5%), PD 22 (24.4%) and AD 29 (32.2%). Patients with ICD discharges had a higher percentage of problems in all EQ5D domains, being significant in PD and AD. Fifty four patients (60%) experienced a significant improvement in QL after ICD implant using the visual analogue scale score (75 points after vs. 50 points before; P<0.001).

CONCLUSIONS

The majority of ICD patients gain QL after implantation, but this gain is more limited in younger patients and those who have received discharges.

An updated review of implantable cardioverter/defibrillators, induced anxiety, and quality of life

During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically. Variables assessed have included recipient age, gender, and social support network. How recipients respond to having the device, particularly after experiencing firing, has been evaluated in light of new depression and anxiety disorder diagnoses as well as premorbid personality structure. Now the picture of what is known is, if anything, cloudier than it was 2 years ago, with little definitive and much contradictory data emerging in most of these categories. It still seems clear that in a significant minority of ICD recipients the device negatively affects quality of life, probably more so if it fires. Education about life with the device before receiving it remains paramount. Reports continue to appear of patients developing new-onset diagnosable anxiety disorders such as panic and posttraumatic stress disorder. Until recently the strongest predictors of induced psychopathology were considered to be the frequency and recency of device firing. It now seems that preimplantation psychologic variables such as degree of optimism or pessimism and an anxious personality style may confer an even greater risk than previously thought. Certainly many variables factor into the induction of psychopathology in these patients. Among these factors are age, gender, and perception of control of shocks, as well as the predictability of shocks and psychologic attributions made by the patient regarding the device. Another source of variability is this population's medical heterogeneity. Some patients receive ICDs after near-death experiences; others get them as anticipatory prophylaxis. Some have longstanding and entrenched heart disease; others were apparently healthy before sudden dangerous arrhythmias. Diagnoses as diverse as myocardial infarction in the context of advanced coronary artery disease and dilated cardiomyopathy after acute viral infection may warrant ICD placement. Moreover the course of cardiac disease after ICD placement may vary from relative stability to continuing disease progression and severe functional compromise. Unless these and other pre- and postimplantation differences are taken into account, it is almost impossible to make meaningful comparisons between studies. Ideally, future research would consist either of large-scale, randomized, prospective studies using validated structured-interview tools to supplement a literature dominated by self-report measures, unstructured assessments, and anecdotal reports, or of smaller studies designed to focus on particular diagnostic subsets. As ICDs become the standard of care for potentially life-threatening arrhythmias, the rate of implantations continues to increase. Because negative emotions have been linked to an increased incidence of arrhythmias, and untreated or unrecognized psychiatric illness can interfere with adaptation to an ICD, assessing and managing both pre-existing and induced psychiatric disorders becomes even more critical. Greater research attention should be paid to determining which patients meet criteria for anxiety disorders before and after implantation and what premorbid traits predispose to postimplantation psychopathology. The authors predict that psychiatrists will be involved increasingly in caring for this population, offering insights into treatment options that increase the likelihood of successful ICD acceptance and decrease the psychosocial costs of these devices.