Anxiety and risk of ventricular arrhythmias or mortality in patients with an implantable cardioverter defibrillator

Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

Burden of mood symptoms and disorders in implantable cardioverter defibrillator patients: a systematic review and meta-analysis of 39 954 patients

AIMS

Implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. Anxiety, depression, and post-traumatic stress disorder (PTSD) are underappreciated symptoms. We aimed to systematically synthesize prevalence estimates of mood disorders and symptom severities, pre- and post-ICD insertions. Comparisons were made with control groups, as well as within ICD patients by indication (primary vs. secondary), sex, shock status, and over time.

METHODS

Databases (Medline, PsycINFO, PubMed, and Embase) were searched without limits from inception to 31 August 2022; 4661 articles were identified, 109 (39 954 patients) of which met criteria.

RESULTS

Random-effects meta-analyses revealed clinically relevant anxiety in 22.58% (95%CI 18.26-26.91%) of ICD patients across all timepoints following insertion and depression in 15.42% (95%CI 11.90-18.94%). Post-traumatic stress disorder was seen in 12.43% (95%CI 6.90-17.96%). Rates did not vary relative to indication group. Clinically relevant anxiety and depression were more likely in ICD patients who experienced shocks [anxiety odds ratio (OR) = 3.92 (95%CI 1.67-9.19); depression OR = 1.87 (95%CI 1.34-2.59)]. Higher symptoms of anxiety were seen in females than males post-insertion [Hedges' g = 0.39 (95%CI 0.15-0.62)]. Depression symptoms decreased in the first 5 months post-insertion [Hedges' g = 0.13 (95%CI 0.03-0.23)] and anxiety symptoms after 6 months [Hedges' g = 0.07 (95%CI 0-0.14)].

CONCLUSION

Depression and anxiety are highly prevalent in ICD patients, especially in those who experience shocks. Of particular concern is the prevalence of PTSD following ICD implantation. Psychological assessment, monitoring, and therapy should be offered to ICD patients and their partners as part of routine care.

Long-term stress conditions and out-of-hospital cardiac arrest risk: a nested case-control study

OBJECTIVE

Patients with stress-related disorders and anxiety are at increased risk of developing cardiovascular disease. However, the risk of out-of-hospital cardiac arrest (OHCA) is scarcely investigated. We aimed to establish whether long-term stress (post-traumatic stress disorder, adjustment disorder) or anxiety is associated with OHCA in the general population.

METHODS

We conducted a nested case-control study in a nationwide cohort of individuals between 1 June 2001 and 31 December 2015 in Denmark. Cases were OHCA patients with presumed cardiac causes. Each case was matched by age, sex and date of OHCA with 10 non-OHCA controls from the general population. HRs for OHCA were derived from Cox models after controlling for common OHCA risk factors. Stratified analyses were performed according to sex, age and pre-existing cardiovascular disease.

RESULTS

We included 35 195 OHCAs and 351 950 matched controls (median age 72 years; 66.8% male). Long-term stress conditions were diagnosed in 324 (0.92%) OHCA cases and 1577 (0.45%) non-OHCA controls, and were associated with higher rate of OHCA (HR 1.44, 95% CI 1.27 to 1.64). Anxiety was diagnosed in 299 (0.85%) OHCA cases and 1298 (0.37%) controls, and was associated with increased rate of OHCA (HR 1.56, 95% CI1.37 to 1.79). We found no interaction with sex, age or history of cardiovascular diseases.

CONCLUSION

Patients with stress-related disorders or anxiety have an increased rate of OHCA. This association applies equally to men and women and is independent from the presence of cardiovascular disease. Awareness of the higher risks of OHCA in patients with stress-related disorders and anxiety is important when treating these patients.

Patients with an implantable cardioverter defibrillator at risk of poorer psychological health during 24 months of follow-up (results from the Danish national DEFIB-WOMEN study)

OBJECTIVE

Identify implantable cardioverter defibrillator (ICD) patients at risk of distress (i.e., depression, anxiety, and ICD concerns) and associated risk factors.

METHOD

First-time ICD patients (n = 1503) from the Danish national DEFIB-WOMEN study completed questionnaires at baseline, 3, 6, 12 and 24 months.

RESULTS

Of patients with low scores on distress, only 4%-7.2% experienced an increase in distress during 24 months of follow-up (FU), while 30.5%-52.5% with increased levels were likely to maintain increased levels at FU. Higher education, higher age, female sex, and good physical functioning at baseline were associated with less depression, anxiety and ICD concerns at FU. Previous psychological problems, smoking, Type D personality, NYHA class III-IV - all assessed at baseline - and shocks during FU were associated with depression, anxiety and ICD concerns.

CONCLUSIONS

Generally, patients' psychological health improved, but patients with increased baseline scores were more likely to have increased scores at FU. We need to be vigilant if patients report elevated distress, particularly if they have depression at baseline, as depression seems more persistent. Given the impact of depression on health-related quality of life and prognosis, they should be screened and monitored closely.

Anxiety and depression as risk factors for ICD shocks and mortality in patients with an implantable cardioverter defibrillator - A systematic review

OBJECTIVE

To examine associations between baseline anxiety and depression and occurrence of ICD shocks and risk of mortality in patients with an implantable cardioverter defibrillator (ICD).

METHOD

We systematically searched EMBASE, PubMed, PsycINFO, and CINAHL for eligible studies fulfilling the predefined criteria.

RESULTS

We included 37 studies based on 25 different cohorts following 35,003 participants for up to seven years. We observed no association between baseline anxiety nor depression and the occurrence of ICD shocks. More than half of the identified studies (respectively 56% and 60%) indicated a significant association between baseline anxiety or depression and increased risk of mortality (anxiety: n = 5, ranging from Hazard ratios (HR):1.02 [Confidence intervals (CI) 95% 1.00-1.03] to HR:3.45 [CI 95% 1.57-7.60]; depression: n = 6, ranging from HR:1.03 [CI 95% 1.00-1.06] to HR:2.10 [CI 95% 1.44-3.05]). We found a significant association between high methodological quality of the primary study and the detection of a significant association (p < 0.01).

CONCLUSIONS

Baseline anxiety and depression are associated with increased risk of mortality in patients with an ICD, but not with occurrence of ICD shocks. Inclusion of baseline anxiety and depression in risk stratification of mortality may be warranted.

Herzerkrankungen im Langzeitverlauf: Wie kann die psychosoziale Versorgung verbessert werden?

Herz-Kreislauf-Erkrankungen, zu denen in erster Linie die koronare Herzerkrankung (KHK), Herzrhythmusstörungen und die Herzinsuffizienz (HI) gehören, sind für die meisten Todesfälle und schwerwiegenden Krankheitsverläufe in der Europäischen Union verantwortlich. Das akute Geschehen steht meist im Vordergrund der klinischen Aufmerksamkeit. Dagegen existieren für den Langzeitverlauf dieser Krankheitsbilder kaum strukturierte Versorgungs- und Therapiekonzepte. Der vorliegende Beitrag gibt auf Grundlage einer Literaturrecherche eine Übersicht über die Langzeitfolgen und die Langzeitversorgung von Herzerkrankungen. Defizite in der psychosozialen Versorgung der Patienten und mögliche Lösungsansätze werden diskutiert.

Bei Patienten mit KHK ergeben sich aufgrund einer mangelhaften psychosozialen Langzeitversorgung häufig Probleme mit der Medikamententreue und der Einhaltung von Verhaltensempfehlungen. Psychische Komorbiditäten reduzieren die Lebensqualität und sind ein Antreiber für gesundheitsschädigendes Verhalten. Patienten mit Herzrhythmusstörungen geraten häufig in einen Teufelskreis aus wiederkehrenden körperlichen Beschwerden in Wechselwirkung mit Angst- und Panikattacken und der damit verbundenen Inanspruchnahme ambulanter, notärztlicher oder stationärer Versorgungseinrichtungen. Im Krankheitsverlauf einer Herzinsuffizienz wird eine klinisch bedeutsam wachsende Anzahl von Patienten mit Antidepressiva behandelt, deren Nutzen eher zweifelhaft ist.

Die erkennbaren Defizite der psychosozialen Langzeitversorgung von Herzerkrankungen können durch die verstärkte Anwendung systematischer kollaborativer Versorgungsmodelle von spezialisierten Versorgungseinrichtungen unter Einbeziehung von Hausärzten behoben und die Lebensqualität der Patienten verbessert werden.

Association between social phobia and the risk of arrhythmia using the Korean National Sample Cohort: a retrospective cohort study

BACKGROUND

Social phobia shares symptoms with arrhythmias, such as palpitations and chest discomfort. However, it is unclear how social phobia is associated with the actual risk of arrhythmia. This study aimed to investigate whether social phobia is associated with the risk of arrhythmia using a nationally representative sample cohort.

METHODS

This retrospective cohort study assessed data from the 2002-2013 Korean National Health Insurance Service National Sample Cohort. Using 1:3 propensity score matching for sex, age, income, and insurance status, 1514 patients with social phobia and 4542 control group patients were included in the study. Social phobia and arrhythmia were defined per the International Classification of Diseases, 10th revision. Using cox proportional hazard regression, hazard ratios (HRs) were calculated to estimate the risk of arrhythmia in patients with social phobia.

RESULTS

There were statistically significant associations between social phobia history and elevated risks of arrhythmia. Patients with social phobia had a higher risk of arrhythmia after adjusting with covariates (HR = 1.78, 95%CI = 1.25-2.55). Among different types of arrhythmias, atrial fibrillation and flutter presented the highest risk (HR = 2.20, CI = 1.06-4.57) compared to paroxysmal tachycardia (HR = 1.07, CI = 0.39-2.91) and other cardiac arrhythmias (HR = 1.83, CI = 1.16-2.89).

CONCLUSION

This study identified the association between social phobia and the risk of arrhythmia in a South Korean representative cohort. These results suggest that social phobia should be treated properly to reduce arrhythmia risks.

Use of handheld electrocardiograph (SnapECG) for the remote monitoring of arrhythmias

Objective

To investigate the value of a SnapECG monitoring in diagnosing arrhythmias compared with the conventional management.

Methods

In the first phase, the SnapECG and 12-lead electrocardiogram (ECG) were simultaneously adopted to detect arrhythmias in 439 hospitalized patients. The accuracies of the SnapECG in detecting different arrhythmias were assessed. In the second phase, 62 patients with palpitations were randomized to receive the SnapECG monitoring or conventional management for 3 months. The diagnosis rate, time of diagnosis, episodes before diagnosis, associated expenses, and scores of the modified European Heart Rhythm Association (EHRA), Self-rating Anxiety Scale (SAS), and the 36-item short-form health survey questionnaire (SF-36) were compared between groups.

Results

In the first phase, the SnapECG monitoring showed a sensitivity of 83.55% and specificity of 96.79% in identifying tachyarrhythmias, and a sensitivity of 95.29% and specificity of 97.54% in identifying bradyarrhythmias. In the second phase, 1642 ECGs were recorded by the SnapECG, among which 290 abnormal ECGs were identified. Compared with the conventional management, the SnapECG monitoring increased the diagnosis rate of symptomatic arrhythmias (70.97% vs. 19.35%, P < 0.05), shortened the time of diagnosis (48.26 ± 36.78 days vs. 71.45 ± 30.01 days, P < 0.05) and consequently reduced the episodes of symptomatic arrhythmias prior to establishing diagnosis. The scores of modified EHRA, SAS, SF-36 significantly improved at 3-month compared with their baseline levels in the SnapECG group.

Conclusions

Remote monitoring with the SnapECG can achieve early diagnosis of symptomatic arrhythmias. However, its sensitivity in identifying P-wave-related arrhythmias warrants further improvement.

Stress, the autonomic nervous system, and sudden death

The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

Device nurse intervention facilitates the patients' adaptation to cardiac shock devices in the remote monitoring era

BACKGROUND

A substantial number of patients with shock devices (implantable cardioverter defibrillators [ICDs] or ICDs with resynchronization [CRTDs]) experience psychological distress.

OBJECTIVE

We investigated the device nurse telephone intervention's effect on improving the patient's adaptation to shock devices, quality of life (QOL), and anxiety in the remote monitoring era.

METHODS

The patient's adaptation to the device, health-related QOL, and anxiety were investigated by the modified Implanted Devices Adjustment-Japan score (IDAS), Short Form-36, and State-Trait Anxiety Inventory (STAI) before and 1-year after the device nurse telephone intervention, performed every 3 months. A total of 95 patients (median age 69 years and 25 females) participated. Sixty patients had ICDs and 35 CRTDs. Structural heart disease was observed in 72 patients, and idiopathic ventricular arrhythmias in the others. The mean left ventricular ejection fraction was 46% ± 15%. The median duration since the device implantation was 5.2 years.

RESULTS

The total IDAS score significantly improved from 28.42 ± 7.11 at baseline to 26.77 ± 7.68 (p = 0.0076) at 1 year. Both the state and trait anxiety significantly improved (from 38.9 ± 9.6 to 35.3 ± 9.0 [<0.0001] and 38.8 ± 10.3 to 36.2±9.8 [p = 0.0044], respectively). The prevalence of patients with a state and trait anxiety of more than 40 decreased from 44 (46%) and 38 (40%) patients before the study to 27 (28 %) and 32 (34 %) at 1 year. The SF-36 mental component summary score significantly increased (50.8 ± 8.3 at baseline to 53.1 ± 7.7 at 1 year, p = 0.0031).

CONCLUSIONS

The device nurse intervention facilitated the patient's adaptation to the shock device, increased the health-related QOL, and reduced the patient's anxiety.

Impact of the COVID-19 lockdown on the arrhythmic burden of patients with implantable cardioverter-defibrillators

BACKGROUND

In Italy, a nationwide full lockdown was declared between March and May 2020 to hinder the novel coronavirus disease 2019 (COVID-19) pandemic. The potential individual health effects of long-term isolation are largely unknown. The current study investigated the arrhythmic consequences of the COVID-19 lockdown in patients with defibrillators (ICDs) living in the province of Ferrara, Italy.

METHODS

Both the arrhythmias and the delivered ICD therapies as notified by the devices were prospectively collected during the lockdown period (P1) and compared to those occurred during the 10 weeks before the lockdown began (P2) and during the same period in 2019 (P3). Changes in outcome over the three study periods were evaluated for significance using McNemar's test.

RESULTS

A total of 413 patients were included in the analysis. No differences were found concerning either arrhythmias or shocks or anti-tachycardia pacing. Only the number of patients experiencing non-sustained ventricular tachycardias (NSVTs) during P1 significantly decreased as compared to P2 (p = 0.026) and P3 (p = 0.009). The subgroup analysis showed a significant decrease in NSVTs during P1 for men (vs. P2, p = 0.014; vs. P3, p = 0.040) and younger patients (vs. P2, p = 0.002; vs. P3, p = 0.040) and for ischemic etiology (vs. P2, p = 0.003). No arrhythmic deaths occurred during P1.

CONCLUSIONS

The complete nationwide lockdown, as declared by the Italian government during the first COVID-19 pandemic peak, did not impact on the incidence of arrhythmias in an urban cohort of patients with ICDs.

Changes in quality of life, depression, general anxiety, and heart-focused anxiety after defibrillator implantation

Aims

The Anxiety‐CHF (Anxiety in patients with Chronic Heart Failure) study investigated heart‐focused anxiety (HFA, with the dimensions fear, attention, and avoidance of physical activity), general anxiety, depression, and quality of life (QoL) in patients with heart failure. Psychological measures were assessed before and up to 2 years after the implantation of an implantable cardioverter defibrillator (ICD) with or without cardiac resynchronization therapy defibrillator (CRT‐D).

Methods and results

One hundred thirty‐two patients were enrolled in this monocentric prospective study (44/88 CRT‐D/ICD, mean age 61 ± 14 years, mean left ventricular ejection fraction 31 ± 9%, and 29% women). Psychological assessment was performed before device implantation as well as after 5, 12, and 24 months. After device implantation, mean total HFA, HFA‐fear, HFA‐attention, general anxiety, and QoL improved significantly. Depression and HFA‐related avoidance of physical activity did not change. CRT‐D patients compared with ICD recipients and women compared with men reported worse QoL at baseline. Younger patients (<median of 63 years) had higher levels of general anxiety and lower levels of HFA‐avoidance at baseline than older patients. After 24 months, groups no longer differed from each other on these scores. Patients with a history of shock or anti‐tachycardia pacing (shock/ATP; N = 19) reported no improvements in psychological measures and had significantly higher total HFA and HFA‐avoidance levels after 2 years than participants without shock/ATP.

Conclusions

Anxiety and QoL improved after device implantation, and depression and HFA‐avoidance remained unchanged. HFA may be more pronounced after shock/ATP. Psychological counselling in these patients to reduce HFA and increase physical activity should be considered.

Anxiety, Mental Stress, and Sudden Cardiac Arrest: Epidemiology, Possible Mechanisms and Future Research

Sudden cardiac arrest (SCA) is a leading cause of mortality and morbidity in affluent societies, which underscores the need to identify persons at risk. The etiology of SCA is however complex, with predisposing and precipitating factors interacting. Although anxiety and mental stress have been linked to SCA for decades, their precise role and impact remain unclear and the biological underpinnings are insufficiently understood. In this paper, we systematically reviewed various types of observational studies (total n = 20) examining the association between anxiety or mental stress and SCA. Multiple methodological considerations challenged the summarizing and interpretation of the findings. For anxiety, the overall picture suggests that it predisposes for SCA in physically healthy populations (unadjusted OR = 2.44; 95% CI: 1.06-5.59; n = 3). However, in populations at risk for SCA (n = 4), associations were heterogeneous but not significant. Anxiety may partly predispose to SCA by contributing to other risk factors such as cardiovascular disease and diabetes mellitus via mechanisms such as unhealthy lifestyle and metabolic abnormalities. Mental stress appears to precipitate SCA, presumably by more directly impacting on the cardiac ion channels that control the heart's electrical properties. This may lead to ventricular fibrillation, the arrhythmia that underlies SCA. To advance this field of research, experimental studies that unravel the underlying biological mechanisms are deemed important, and most easily designed for mental stress as a precipitating factor because of the short timeframe. These proof-of-concept studies should examine the whole pathway from the brain to the autonomic nervous system, and eventually to cardiac ion channels. Ultimately, such studies may facilitate the identification of persons at risk and the development of novel preventive strategies.

Anxiety, depression, ventricular arrhythmias and mortality in patients with an implantable cardioverter defibrillator: 7 years' follow-up of the MIDAS cohort

OBJECTIVE

To examine whether anxiety and depression at time of implantation of an implantable cardioverter defibrillator (ICD) is associated with ventricular arrhythmias (VAs) and mortality 7 years later.

METHODS

A cohort of 399 patients (80% men; mean (SD) age = 58.3 (12.2)) implanted with an ICD completed the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory at time of implantation. Patients were followed up for VAs and mortality at 7 years.

RESULTS

At 7-years follow-up, 34% of the patients had died and 38% had experienced VAs. Baseline depression (score ≥ 8) (HR:2.10; 95% CI:1.44-3.05, p < 0.001) was associated with 7-year mortality in adjusted analyses while state anxiety (score ≥ 40) (HR:1.45; 95% CI:1.02-2.06, p = 0.039) and trait anxiety (score ≥ 40) (HR:1.51; 95% CI:1.06-2.16, p = 0.022) showed a trend towards an association with mortality. No association was found between VAs and anxiety and depression. There was a dose-response relationship with higher burden of anxiety (HR:2.13; 95% CI:1.31-3.46, p = 0.002) and depression (HR:2.13; 95% CI:1.33-3.42, p = 0.002) measured with the HADS (scores < 8, 8-10 and > 10) being associated with an increased risk of mortality.

CONCLUSION

Patients with depression had greater risk of mortality, whereas anxiety only showed a trend. Neither anxiety nor depression was associated with VAs during follow-up.

Validity of the newly developed 4-item ANXiety-scale in patients with an implantable cardioverter defibrillator: A 12-month follow-up study

BACKGROUND

Subclinical anxiety symptoms are associated with risk of impaired mental and physical health status, ventricular tachyarrhythmias and mortality, in patients with an implantable cardioverter defibrillator (ICD). This study evaluates the validity of the brief and new 4-item Anxiety Scale (ANX4) and its predictive value in relation to health status 12-months post ICD implantation.

METHODS

A total of 288 ICD patients completed the ANX4 questionnaire. Factor analysis was performed to assess the validity of the scale. In a subsample of N = 212 patients, regression analysis was performed to assess questionnaires' predictive value of health status at 12-months follow-up.

RESULTS

Analyses of the ANX4 revealed a one-factor structure with a high internal consistency (α = 0.894). The ANX4 correlated significantly with existing generic and disease specific measures of anxiety symptoms STAI-S (r = 0.62), GAD-7 (r = 0.58), HADS-A (r = 0.66) and ICD related concerns (ICDC) (r = 0.44). Baseline anxiety symptoms were associated with lower levels of physical (β = -0.276; p < .001) and mental (β = -0.551; p < .001) health status 12-months post ICD implantation, adjusting for demographic and clinical variables.

CONCLUSIONS

The 4-item ANX4 shows to be a valid measure of anxiety symptoms in ICD patients and predicts physical and mental health status up to 12 months follow-up. Further studies are warranted to replicate these findings, determine the cut-off score for clinical relevant symptoms, and whether the ANX4 can be used in other populations.

Anger and long-term mortality and ventricular arrhythmias in patients with a first-time implantable cardioverter-defibrillator: data from the MIDAS study

Aims

Psychosocial factors increase risk for incident heart disease and poor prognosis. In patients with an implantable cardioverter-defibrillator (ICD), negative emotions have been associated with increased mortality risk, although the association with ventricular arrhythmias (VAs) is less consistent. Anger has been linked to incident ICD shocks, but no prospective study has examined the association of anger (state and trait) with mortality or VAs in the ICD population. In a consecutively recruited cohort of first-time ICD patients, we examined the association of state and trait anger with 7-year mortality risk and time to first VA.

Methods and results

A consecutive cohort of patients implanted with a first-time ICD (n = 388; 80% men) between 2003 and 2010 completed the State-Trait Anger Scale and were followed for 7 years. Outcomes were mortality and time to first appropriate ICD therapy. State anger at the time of implant was associated with increased mortality risk in adjusted analyses, with a 1-point increase in score on the state anger measures associated with a 5% [hazard ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.015] increased 7-year mortality risk. We found no statistically significant differences in mortality risk for trait anger, nor an effect for state or trait anger on time to first treated VA (all ps &gt; 0.05).

Conclusion

This is the first study to examine the association of state and trait anger with long-term clinical outcomes in ICD patients. Evaluating anger reduction strategies in newly implanted ICD patients, such as self-regulation or mindfulness techniques, may be warranted for reducing mortality risk.

Prevalence of anxiety and risk associated with ventricular arrhythmia in patients with an implantable cardioverter defibrillator

BACKGROUND

Anxiety has been associated with adverse clinical outcomes in patients who have received an implantable cardioverter defibrillator (ICD). However, results are inconclusive likely due to different measures being used to assess anxiety. Hence, the current study aims to examine the prevalence and the association between anxiety, ventricular tachyarrhythmia's (VTa's) and all-cause mortality, respectively.

METHODS

Patients who received an ICD for the first time were recruited from 6 Dutch referral hospitals as part of the WEBCARE trial. Patients filled in validated questionnaires (GAD-7, STAI-S, HADS-A, ANX4, ICDC, FSAS) to assess their baseline anxiety symptomatology. Logistic regression analysis and Cox Regression analysis were performed to examine the association between anxiety with 1) VTa's and 2) mortality, respectively.

RESULTS

A total of 214 Patients were included in the analysis with mean age 58.9 and 82.7% being male. The prevalence rates of anxiety varied depending on which questionnaire was used 12.4% (GAD-7), 17.5% (HADS-A), and 28.1% (STAI-S). (Cox) Regression analysis revealed that none of the anxiety measures was associated with VTa's or all-cause mortality in the current sample. Stratifying the sample by gender, the analysis showed that GAD-7, STAI-S, and ANX4 scores were associated with increased risk of VTa's but only in male patients.

CONCLUSIONS

Prevalence rates of anxiety varied depending on the measurement tool used. No significant association between anxiety and VTa's and all-cause mortality was observed in the total sample. GAD-7, STAI-S, and ANX4 were associated with increased risk for VTa's but only in male patients.

Personality traits, ventricular tachyarrhythmias, and mortality in patients with an implantable cardioverter defibrillator: 6 years follow-up of the WEBCARE cohort

OBJECTIVE

Risk stratification within the ICD population warrants the examining of the role of protective- and risk factors. Current study examines the association between Type D personality, pessimism, and optimism and risk of ventricular tachyarrhythmias (VTa's) and mortality in patients with a first-time ICD 6 years post implantation.

METHODS

A total of 221 first-implant ICD patients completed questionnaires on optimism and pessimism (Life Orientation Test) and Type D personality (Type D scale DS14) 10 to 14 days after implantation. VTa's and all-cause mortality 6 years post implant comprised the study endpoints.

RESULTS

Ninety (40.7%) patients had experienced VTa's and 37 (16.7%) patients died, 12 (5.4%) due to a cardiac cause. Adjusted logistic regression analysis showed that pessimism was significantly associated with increased risk of VTa's (OR = 1.09; 95% CI = 1.00-1.19; p = .05). Type D personality (OR = 1.05; 95% CI = 0.47-2.32; p = .91) and optimism (OR = 1.00; 95% CI = 0.90-1.12; p = .98) were not associated with VTa's. None of the personality types were associated with mortality.

CONCLUSION

Pessimism was associated with VTa's but not with mortality. No significant association with either of the endpoints was observed for Type D personality and optimism. Future research should focus on the coexistent psychosocial factors that possibly lead to adverse cardiac prognosis in this patient population.

[Cardiac implantable electronic devices and health-related quality of life]

Patients, scientists and healthcare providers are increasingly interested in identifying interventions that not only reduce mortality but also improve symptoms, function and health-related quality of life. Health-related quality of life is a strong, independent predictor of mortality, cardiovascular events, hospitalization and treatment costs in patients with cardiac diseases. Remote monitoring of pacemakers has a positive effect on health-related quality of life and functional capacity and is equivalent to monitoring these patients in hospitals. Implantation of an implantable cardioverter defibrillator has a major impact on mental health, with the majority of patients experiencing the fear of ICD shocks as particularly detrimental to the quality of life. Variables, such as age, gender and duration of implantation should be considered in the assessment and planning of strategies for improving the quality of life of patients with electronic implantable cardiac devices.

Healthcare utilization in patients with first‐time implantable cardioverter defibrillators (data from the WEBCARE study)

Background

Knowledge of the level of healthcare utilization (HCU) and the predictors of high HCU use in patients with an implantable cardioverter defibrillator (ICD) is lacking. We examined the level of HCU and predictors associated with increased HCU in first‐time ICD patients, using a prospective study design.

Methods

ICD patients (N = 201) completed a set of questionnaires at baseline and 3, 6, and 12 months after inclusion. A hierarchical multiple linear regression with three models was performed to examine predictors of HCU.

Results

HCU was highest between baseline and 3 months postimplantation and gradually decreased during 12 months follow‐up. During the first year postimplantation, only depression (β = 0.342, P = 0.002) was a significant predictor. Between baseline and 3 months follow‐up, younger age (β = −0.220, P < 0.01), New York Heart Association class III/IV (β = 0.705, P = 0.01), and secondary indication (β = 0.148, P = 0.05) were independent predictors for increased HCU. Between 3 and 6 months follow‐up, younger age (β = −0.151, P = 0.05) and depression (β = 0.370, P < 0.001) predicted increased HCU. Between 6 and 12 months only depression (β = 0.355, P = 0.001) remained a significant predictor.

Conclusions

Depression was an important predictor of increased HCU in ICD patients in the first year postimplantation, particularly after 3 months postimplantation. Identifying patients who need additional care and provide this on time might better meet patients’ needs and lower future HCU.

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

Background:

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

Aims:

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

Methods:

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

Results:

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

Conclusions:

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

Mental Stress and Ventricular Arrhythmias

Anger and other negative emotions can precipitate sudden death, as shown in studies of population stressors. Clinical studies of patients with implantable defibrillators demonstrate that anger can trigger ventricular arrhythmias. Long-term negative emotions also increase vulnerability to arrhythmias. Mechanisms linking anger and arrhythmias include autonomic changes, which alter repolarization, possibly enhanced in patients with sympathetic denervation, which in turn trigger potentially lethal polymorphic ventricular tachycardias. Interventions which decrease negative emotions and resultant autonomic responses may be therapeutic in patients with implantable cardioverter defibrillators.

Prognostic association of cardiac anxiety with new cardiac events and mortality following myocardial infarction

BACKGROUND

General anxiety and depressive symptoms following a myocardial infarction are associated with a worse cardiac prognosis. However, the contribution of specific aspects of anxiety within this context remains unclear.

AIMS

To evaluate the independent prognostic association of cardiac anxiety with cardiac outcome after myocardial infarction.

METHOD

We administered the Cardiac Anxiety Questionnaire (CAQ) during hospital admission (baseline, n = 193) and 4 months (n = 147/193) after discharge. CAQ subscale scores reflect fear, attention, avoidance and safety-seeking behaviour. Study end-point was a major adverse cardiac event (MACE): readmission for ischemic cardiac disease or all-cause mortality. In Cox regression analysis, we adjusted for age, cardiac disease severity and depressive symptoms.

RESULTS

The CAQ sum score at baseline and at 4 months significantly predicted a MACE (HR_baseline = 1.59, 95% CI 1.04-2.43; HR_4-months = 1.77, 95% CI 1.04-3.02) with a mean follow-up of 4.2 (s.d. = 2.0) years and 4.3 (s.d. = 1.7) years respectively. Analyses of subscale scores revealed that this effect was particularly driven by avoidance (HR_baseline = 1.23, 95% CI 0.99-1.53; HR_4-months = 1.77, 95% CI 1.04-1.83).

CONCLUSIONS

Cardiac anxiety, particularly anxiety-related avoidance of exercise, is an important prognostic factor for a MACE in patients after myocardial infarction, independent of cardiac disease severity and depressive symptoms.

Anxiety as a risk factor in cardiovascular disease

PURPOSE OF REVIEW

The narrative review covers recent studies of anxiety as a companion in cardiovascular disease.

RECENT FINDINGS

Prospective population-based studies and studies of cases with known cardiovascular disease have been conducted, as well as studies of intervention with coronary bypass grafting, heart transplants, and implantable cardioverter-defibrillators, and subsequent rehabilitation programs. Mental stress-induced myocardial ischemia (MSIMI) stands for this emerging research arena.

SUMMARY

Anxiety has emerged as perhaps the most important risk factor for cardiovascular disease, determining other known risk factors, such as depression, substance use, overweight, and a sedentary lifestyle. Anxiety also increases the risk of major cardiac events in coronary heart disease. There is a need for elucidating the influence of anxiety in takotsubo and in white-coat hypertension. Managing anxiety is of vital importance in patients who have received heart transplants, to ascertain adherence to immunosuppressants.

Association between anxiety and mortality in patients with coronary artery disease: A meta-analysis

BACKGROUND

Depression and anxiety are common in patients with coronary artery disease (CAD). Although depression clearly has been associated with mortality in this population, the relationship between anxiety and mortality is less clear. Accordingly, we performed a series of meta-analyses to (1) examine the relationship between anxiety and mortality in patients with established CAD and (2) determine if this relationship differs in patients with stable CAD compared to those who have just had an acute coronary syndrome (ACS).

METHODS AND RESULTS

Systematic literature searches identified 44 articles (total N = 30,527) evaluating the prospective relationship between anxiety and mortality in individuals with established CAD. A series of 8 adjusted and unadjusted meta-analyses were performed to examine this relationship across all patients, with sensitivity analyses completed in post-ACS and stable CAD cohorts. In unadjusted analyses, anxiety was associated with a moderate increase in mortality risk (odds ratio 1.21 per SD increase in anxiety). However, when adjusting for covariates, nearly all associations became nonsignificant. In sensitivity analyses, anxiety was associated with an increased risk of poor outcomes in the stable CAD-but not post-ACS-cohort.

CONCLUSIONS

These analyses confirm that anxiety is associated with increased risk of mortality in patients with CAD; however, this relationship is not as strong as that of depression and may be explained partly by other clinical factors. If anxiety screening is performed, it should be performed during a period of clinical stability and should target anxiety disorders rather than anxiety symptoms alone.

Is Internet use associated with anxiety in patients with and at risk for cardiomyopathy?

OBJECTIVE

The aim of the study was to determine the relation between online health information seeking behavior and anxiety level among a sample of patients with manifested cardiomyopathy or at risk for cardiomyopathy.

METHODS

The research is a cross-sectional study conducted among 104 patients with cardiomyopathy diagnosis and patients at risk for cardiomyopathy. Patients completed 3 different questionnaires: Use of Internet Health Information questionnaire about the use of Internet, Short Form SF-12 items questionnaire on quality of life, and State-Trait Anxiety Inventory measuring general anxiety levels.

RESULTS

Forty-eight patients had a diagnosis of primary or secondary cardiomyopathy, and 56 patients, with conditions predisposing to cardiomyopathy. Eighty-five percent of the considered population is surfing the Internet to obtain nonspecific information about health in general, and the 65% use it to look specifically for heart disease. For both groups of patients with cardiomyopathy and at risk for cardiomyopathy, online health information seeking behavior is associated with substantially lower state anxiety levels (P = .041).

CONCLUSION

Web use, as a source of health information, has been shown to be associated with anxiety reduction in patients with or at risk for cardiomyopathy, suggesting that Internet technology can be a useful instrument due to its informational power and its potentially therapeutic value.

Behavioral influences on cardiac arrhythmias

Stress can trigger both ventricular and atrial arrhythmias, as evidenced by epidemiological, clinical, and laboratory studies, through its impact on autonomic activity. Chronic stress also increases vulnerability to arrhythmias. Novel therapies aimed at decreasing the psychological and physiological response to stress may decrease arrhythmia frequency and improve quality of life.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

clinicaltrials.gov. Identifier: NCT00895700.

State of the art of ICD programming: Lessons learned and future directions

The lifesaving benefits of implantable cardioverter defibrillator (ICD) therapy are more and more weighted against possible harm (e.g. unnecessary device therapy, procedural complications, device malfunction etc.) which might have adverse effects on patients' perceived health status and quality of life. Hence, there has been an increasing interest in the optimisation of ICD programming to prevent inappropriate and appropriate but unnecessary device therapy. The purpose of the current report is to give an overview of research into the optimisation of ICD programming and present the design of the on-going ENHANCED-ICD study. The ENHANCED-ICD study is a prospective, safety monitoring study enrolling 60 primary and secondary prophylactic ICD patients at the University Medical Center Utrecht. Patients implanted with any type of ICD with SmartShock technology(TM), and between 18-80 years of age, were eligible to participate. In all patients a prolonged detection of 60/80 intervals was programmed. The primary objective of the study is to investigate whether enhanced programming to further reduce ICD therapies is safe. The secondary objective is to examine the impact of enhanced programming on (i) antitachycardia pacing and shocks (both appropriate and inappropriate) and (ii) quality of life and distress. The first results of the ENHANCED-ICD study are expected in 2015.

Long-term mortality risk in patients with an implantable cardioverter-defibrillator: Influence of heart rate and QRS duration

BACKGROUND

A paucity of studies has investigated the role of autonomic cardiac regulation as well as cardiac conduction in relation to prognosis in implantable cardioverter-defibrillator (ICD) patients. Therefore, we examined the association of heart rate and QRS duration with long-term mortality risk in first-time ICD patients, adjusting also for measures of emotional distress.

METHODS

Resting heart rate and QRS duration were assessed prior to ICD implantation in 448 patients. Primary study endpoint was all-cause mortality (up to 6.0 year follow-up, median follow-up of 5.6 years (IQR: 1.9)). The impact of heart rate and QRS duration on time to all-cause mortality was separately assessed with Cox proportional hazard regression analysis, adjusting for clinical factors and symptoms of depression and anxiety.

RESULTS

Mean (SD) heart rate was 68.0 ± 13.3 bpm and mean QRS duration was 130.9 ± 36.9 ms. Heart rate of ≥80 bpm was associated with increased risk of mortality (HR=1.86; 95% CI=1.15-3.00; p=.011) in unadjusted analysis. In adjusted analyses, this relationship remained significant both with depression (HR=1.86, 95% CI=1.12-3.09; p=.017) and anxiety (HR=1.82, 95% CI=1.10-3.03; p=.021) and clinical measures as covariates. QRS duration of ≥120 ms was associated with impaired prognosis in unadjusted analysis (HR=2.00, 95% CI=1.27-3.14; p=.003), but was reduced to non-significance in adjusted analysis when medical comorbidities were included (HR=1.15, 95% CI=0.70-1.89; p=.60).

CONCLUSIONS

This study shows that increased heart rate is associated with impaired prognosis. Since heart rate is a relatively easy measurable parameter of autonomic functioning, heart rate should be included as a measure for risk stratification in daily clinical practice.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Psychological distress in patients with a left ventricular assist device and their partners: an exploratory study

BACKGROUND

Left ventricular assist device (LVAD) therapy is increasingly used in patients with advanced heart failure, and may have a significant psychological impact on both patients and their partners. Hence, we examined the distress levels of LVAD patients and their partners.

METHODS

Anxiety, depression and post-traumatic stress disorder (PTSD) were assessed at 3-4 weeks after implantation, and at 3 and 6 months follow-up in 33 LVAD patients (73% men; mean age=54±10 years) and 33 partners (27% men; mean age=54±11 years).

RESULTS

The prevalence of anxiety in LVAD partners was significantly higher compared to LVAD patients at baseline (48% vs. 23%, p=0.03) and 3 months follow-up (44% vs. 15%, p=0.02), but not at 6 months follow-up (p=0.43). No differences were found for depression and PTSD (ps>0.05). Scores between the LVAD patients and partners showed only a significant correlation at baseline between the anxiety, depression and PTSD score of the patient and the depression score of the partner (r anx=0.40, p=0.04; rdep=.40, p=0.04; r PSTD=0.46, p=0.05). Multivariable analyses showed no significant association between the role (patient vs. partner) and anxiety, depression and PTSD over time after correction for age, gender and clinical covariates. However, after correction for Type D personality and the use of psychotropic medication the LVAD partners showed significantly higher anxiety (F=6.95, p=0.01) and depression (F=3.94, p=0.04) scores over time compared to LVAD patients.

CONCLUSION

LVAD partners had significantly higher levels of anxiety than LVAD patients. Emotional distress of LVAD partners should gain more attention, as partners are an essential source of support for LVAD patients.

Psychological distress and arrhythmia: risk prediction and potential modifiers

The connection between the heart and the brain has long been anecdotally recognized but has systematically been studied only relatively recently. Cardiac arrhythmias, especially ventricular arrhythmias that can lead to sudden cardiac death, remain a major public health concern and there is mounting evidence that psychological distress plays a critical role both as a predictor of high-risk cardiac substrate and as an inciting trigger. The transient, unpredictable nature of emotions and cardiac arrhythmias has made their study challenging, but evolving technologies in monitoring and imaging along with larger epidemiological data sets have encouraged more sophisticated studies examining this relationship. Here we review the research on psychological distress including anger, depression and anxiety on cardiac arrhythmias, insights into proposed mechanisms, and potential avenues for future research.