Depression and anxiety status of patients with implantable cardioverter defibrillator and precipitating factors

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.

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion

AIMS

Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation.

METHODS AND RESULTS

The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151).

CONCLUSION

Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

Prevalence of depression and its association with quality of life in patients after pacemaker implantation during the COVID-19 pandemic: A network analysis

Background

This study was designed to investigate the prevalence and predictors of depression in patients after pacemaker implantation during the COVID-19 pandemic in addition to identifying specific depressive symptoms associated with quality of life (QOL) using network analysis (NA).

Methods

This cross-sectional, observational study was conducted in China between July 1, 2021, and May 17, 2022. Descriptive analysis was used to calculate depression prevalence. Univariate analyses were used to compare differences in demographic and clinical characteristics between depressed and non-depressed patients following pacemaker implantation. Binary logistic regression analysis was used to assess factors independently associated with depression. Network analysis “expected influence,” and flow function indexes were used to identify symptoms central to the depression network of the sample and depressive symptoms that were directly associated with QOL, respectively. Network stability was examined using a case-dropping bootstrap procedure.

Results

In total, 206 patients implanted with a pacemaker met the study entry criteria and completed the assessment. The overall prevalence of depression (PHQ-9 total score ≥ 5) was 39.92% [95% confidence interval (CI) = 29.37−42.47%]. A binary logistic regression analysis revealed that patients with depression were more likely to report a poor health status (p = 0.031), severe anxiety symptoms (p < 0.001), and fatigue (p < 0.001). In the network model for depression, “Sad mood,” “Poor Energy,” and “Guilt” were the most influential symptoms. “Fatigue” had the strongest negative association with QOL, followed by “Sad mood” and “Appetite”.

Conclusion

Depression is common among patients having undergone pacemaker implantation during the COVID-19 pandemic. Anxiety, central symptoms of depression (i.e., “Sad mood”, “Poor Energy”, and “Guilt”) and depressive symptoms linked to QOL (i.e., “Sad mood”, “Appetite”, and “Fatigue”) identified in this study are promising targets for interventions and preventive measures for depression in patients who have undergone pacemaker implants.

Antitachycardia pacing success in implantable cardioverter-defibrillators by patient, device, and programming characteristics

BACKGROUND

Antitachycardia pacing (ATP) is an established implantable cardioverter-defibrillator (ICD) therapy that terminates ventricular tachycardias (VTs) without painful ICD shocks. However, factors influencing ATP success are not well understood.

OBJECTIVE

The purpose of this study was to examine ATP success rates by patient, device, and programming characteristics.

METHODS

This retrospective analysis of the PainFree SmartShock Technology study included spontaneous ATP-treated monomorphic VT episodes. ATP success rates were calculated for various factors. Also, the relationship of ATP programming on shock burden and syncope were investigated.

RESULTS

Of the 2770 enrolled patients (2200 [79%] male; mean age 65 years), 1699 (61%) received an ICD and 1071 (39%) a cardiac resynchronization therapy - defibrillator. ATP had >80% rate of success for terminating VTs overall, with similar rates observed between ICD and cardiac resynchronization therapy - defibrillator devices (82.2% vs 80.3%, respectively; P = .81) as well as between primary and secondary prevention patients with ICDs (77.2% vs 83.9% respectively; P = .25). Arrhythmias with a median cycle length of ≥320 ms had a significantly higher ATP success rate (88.0%; 95% confidence interval 84.8%-90.6%). The cumulative percentage of ATP success increased from 71% at 1 ATP sequence delivered to 87% at ≥8 sequences delivered. Programming more ATP sequences was associated with lower shock burden (P = .0005). There was no evidence that more sequences were associated with higher rates of syncope (P = .16).

CONCLUSION

Delivering more ATP sequences resulted in a higher overall success of terminating VTs, while programming more ATP was associated with decreased shock burden and no evidence of increased syncope or acceleration. This suggests that more ATP sequences should be programmed when possible, but confirmation in prospective studies will be necessary.

Depression and cardiovascular diseases

Depression is a well-known risk factor for adverse cardiovascular outcomes in patients with cardiovascular diseases. The prevalence of depression in patients with cardiovascular diseases has been reported to be approximately 20 %. A two-step depression screening protocol using the 2-item Patient Health Questionnaire (PHQ-2) and the 9-item Patient Health Questionnaire (PHQ-9) is recommended for patients with cardiovascular diseases. Cardiovascular diseases and depression share a common pathology, including increased activity of the sympathetic nervous system, hyperactivity of hypothalamic-pituitary-adrenal axis, and inflammation. Psychosocial and environmental factors are also associated with depression and cardiovascular outcomes. Randomized controlled trials of antidepressant treatment for patients with depression and cardiovascular diseases have shown no advantage regarding cardiovascular outcomes. However, improvement in depressive symptoms, regardless of the method, may lead to a reduction in subsequent cardiovascular events. A collaborative approach between cardiologists and psychiatrists is recommended to manage depression in patients with cardiovascular diseases. Future research should identify more specific targets for treating patients with cardiovascular diseases, involve collaboration with professionals across fields, and establish community support systems.

Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia

BACKGROUND

In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain.

OBJECTIVES

This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs).

METHODS

The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications.

RESULTS

In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929).

CONCLUSIONS

In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562).

Psychological Disturbances and Their Association with Sleep Disturbance in Patients Admitted for Arrhythmia Diseases

OBJECTIVES

This study aimed to assess the depression and anxiety status and their association with sleep disturbance among one single center Chinese inpatients with arrhythmia and help cardiologists better identify patients who need psychological care.

METHODS

A cross-sectional survey was conducted among 495 inpatients with arrhythmia treated in Fuwai Hospital from October to December 2019. The psychological status and sleep quality were assessed using the Zung Self-Rating Anxiety Scale (SAS), the Zung Self-Rating Depression Scale (SDS) and the Pittsburgh Sleep Quality Index (PSQI). Multivariate logistic regression was used to identify the potential risk factors for anxiety and depression.

RESULTS

The mean age of the participants was 52.8 ± 14.4 years, and 58.0% were male. Approximately 18.3% were in an anxious state, and 33.5% were in a depressive state. In multivariate logistic regression, age from 50 to 59 (p = 0.03), unemployment (p = 0.026) and sleep disturbance (p < 0.001) were the risk factors for anxiety status. Cardiac implanted electronic devices (CIEDs) (p = 0.004) and sleep disturbance (p < 0.001) were the risk factors for depression status. A total of 150 patients (30.3%) were categorized as having poor sleep quality (PSQI > 7). The adjusted odds ratio (OR) of having poor sleep quality was 4.30-fold higher in patients with both anxiety and depression (OR: 4.30; 95% confidence interval [CI]: 2.52-7.35); 2.67-fold higher in patients with depression (OR: 2.67; 95% CI: 1.78-4.00); and 3.94-fold higher in patients with anxiety (OR: 3.94; 95% CI: 2.41-6.44).

CONCLUSIONS

Psychological intervention is critical for Chinese inpatients with arrhythmia, especially for patients aged 50-59, unemployed, or those using CIEDs. Poor sleep quality could be an important risk factor linked to psychological disturbances.

Anxiety and depression in inherited channelopathy patients with implantable cardioverter-defibrillators

Background

Implantable cardioverter-defibrillators (ICDs) are an effective treatment in some patients with inherited heart disease, including inherited channelopathies, yet they have also been shown to impact patients' psychological health.

Objective

We sought to improve understanding of the level of anxiety and depression as well as device acceptance among inherited channelopathy patients with an ICD.

Methods

Eligible patients seen at Johns Hopkins Hospital were sent a survey, which included the Hospital Anxiety and Depression Scale (HADS), Cardiac Anxiety Questionnaire (CAQ), and the Florida Patient Acceptance Survey (FPAS). Student t tests and χ² tests were used to identify associations with abnormal anxiety and depression scores.

Results

Among eligible patients (n = 65), 32 individuals (49%) completed the survey. The rate of device-related complications was 34%, and 41% of patients experienced 1 or more ICD shocks. Twelve patients (38%) had an abnormal HADS anxiety subscore and 5 patients (16%) had an abnormal HADS depression subscore (score ≥ 8). Secondary-prevention ICDs were associated with an abnormal HADS anxiety subscore (P = .03). Experiencing ICD shock(s), device complications, age, sex, and family history of sudden cardiac death were not statistically associated with anxiety or depression. Overall, respondents demonstrated high device acceptance by FPAS (79.9 ± 2.9, maximum total score 100) and moderately high cardiac-specific anxiety by CAQ total score (1.53 ± 0.12).

Conclusion

A high prevalence of generalized anxiety was identified among inherited channelopathy patients with ICDs. High device acceptance and lack of association with ICD shocks or complications indicate that further research is necessary to understand this increased incidence.

Resilience, Cardiological Outcome, and Their Correlations With Anxious-Depressive Symptoms and Quality of Life in Patients With an Implantable Cardioverter Defibrillator

Background: Resilience is proven as a protective factor against the development of psychiatric disorders, and it has gained clinical relevance in the development and progression of cardiovascular pathology. The authors performed a longitudinal study on patients with implantable cardioverter defibrillator (ICD) with the primary aim to highlight the possible existence of a correlation between individual resilience capacity, depressive and anxiety symptoms, and quality of life in terms of outcomes. The secondary aim was to analyze the differences between patients with major cardiac events in the follow-up and patients without cardiac events with respect to the previous variables. Materials and Methods: A total of 80 patients enrolled in the Cardiology Unit were evaluated at T₀ and during the follow-up through the following scales: the 14-item Resilience Scale (RS-14), the Hospital Anxiety and Depression Scale (HADS), and the World Health Organization Quality of Life-Brief Version (WHOQOL-Bref). Results: A significant linear correlation between resilience and all the areas of quality of life at T₀, T₁, and T₂ emerged. A negative correlation between resilience and anxiety and depressive symptoms emerged, as well as between depression and anxiety and quality of life. Patients with cardiac events during the follow up have shown a worse quality of life and the onset of anxiety-depressive symptoms over time, without changes to the resilience scores. Patients without cardiac events showed an increasing trend in resilience scores. Discussion: Given the speed and simplicity of use of the RS-14 scale, it seems promising to further investigate the real clinical usefulness of this instrument in the cardiology field.

Living at the boundary between life and death: A qualitative study of how patients' lives are impacted by the implantable cardioverter defibrillator

AIMS

To examine the effect on patients' lives of implantable cardioverter defibrillator implantation and their experiences of worry about death.

DESIGN

A descriptive phenomenological design.

METHODS

Participants with implantable cardioverter defibrillators were recruited through purposive sampling with maximum variation in Antalya, Turkey. Data collection included individual semi-structured interviews conducted between September 2018 - May 2019. Interviews were audio recorded, transcribed verbatim, and analysed by Giorgi's descriptive phenomenology method.

RESULTS

Twenty-six individuals with implantable cardioverter defibrillators participated in the study. Analysis of the data resulted in three themes and 10 subthemes. The first theme was the physical impact of the device on the body with the subthemes changes in physical functioning and like part of the body; the second theme was social impact in daily life and adaptation to restrictions with the subthemes necessary for life, restrictive behaviours of day-to-day life and Seeking social support and the third theme was the emotional impact of the experience of shock and worry about death with the subthemes inevitable truth, living at the boundary, every shock is like you are going to die, advancing on an uncertain path, and trust in life insurance.

CONCLUSION

It was found in this study that the implantation of implantable cardioverter defibrillators affected patients physically, socially, and emotionally in many ways. It is thought that this study will raise the awareness of health professionals and will support a holistic approach, increasing the quality of care.

IMPACT

Although the implantation of the cardioverter defibrillator is greatly effective in protecting against sudden cardiac death, for patients it brings with it many physical, social, and emotional problems. This study can contribute to health professionals planning individual education in coping with changes, an increase in group-based counselling to support the sharing of experience, social networks, and monitoring programs to improve care.

Remote monitoring of implantable cardioverters defibrillators: a comparison of acceptance between octogenarians and younger patients

Background

Remote monitoring (RM) is increasingly employed for all types of cardiac implantable devices (CIED). However, there are only limited data on the acceptance of RM by the elderly. The aim of our study was to ascertain how octogenarians assess RM technologies compared to younger, presumably technically more literate patients, and what concerns or technical problems the system presents to both groups of patients.

Methods

The trial was designed as a descriptive, register-based single-center study. The study population consisted of all consecutive patients ≥ 80 years of age (group A, n = 94) and all consecutive patients aged ≤ 40 years (group B, n = 71), who had undergone implantation of an implantable cardioverter-defibrillator (ICD) between the years of 2009 and 2018 and were using a Home Monitoring^TM (HM, Biotronik, Berlin, Germany) system. All patients fulfilling entry criteria were approached with a request to participate in the survey.

Results

A total of 85 (90.4%) and 65 (91.5%) valid surveys were obtained for groups A and B, respectively. Ninety-two percent of patients in both groups (P = 0.903) were satisfied with the limited number of planned ambulatory follow-ups (i.e., once a year). All patients in both groups (100%) reported that they were satisfied with the HM system, and 97% and 94% of patients in Groups A and B, respectively, ranked it highly beneficial (P = 0.68). A significant proportion of patients in both groups were completely unaware of any health-related benefits associated with the use of the HM system (42% in Group A vs. 49% in Group B, P = 0.4). Among the most frequently reported personal benefits of HM were a sense of safety and security and savings on travel expenses and time. 5% and 9% of patients in Groups A and B, respectively, reported that usage of HM caused them some degree of psychological stress (P = 0.27). Nearly all patients in both groups reported receiving information on HM from their doctor after ICD implantation. None of Group A reported receiving information from a nurse either before or after ICD implantation, while 14% of Group B patients reported receiving information from a nurse after, but not before ICD implantation. Seven and 51% (P < 0.0001) of patients in Group A and B, respectively, sought additional information about HM post-discharge.

Conclusions

The HM system received good marks and was much appreciated, even in patients over 80 years of age. The level of acceptance and potential psychological stress resulting from RM technology appears to be about the same in older patients as in younger patients. The majority of octogenarians either did not fully understand the clinical benefits of the system or mistakenly thought that the HM system was a substitute for emergency 24-h surveillance. These results highlight the need for better patient education relative to RM technology, with one option being to delegate more of this educational process to specially trained nurses.

Improving the care for female subcutaneous ICD patients: A qualitative study of gender-specific issues

BACKGROUND

The subcutaneous implantable cardioverter-defibrillator (S-ICD) consists of a large generator and is implanted near the left breast. This might lead to discomfort and problems with self-perception and sexuality, especially in the female population. We aimed to assess the issues that female S-ICD patients experience and to provide practical guidance for cardiologists and implanters on minimizing these issues.

METHODS

For this retrospective single-center study, we conducted semi-structured interviews with four female S-ICD patients and processed their experiences into a questionnaire. This consisted of three open questions and 17 statements that participants could answer through a five-point Likert scale. The questionnaire was subsequently sent to all female adult patients who received an S-ICD between February 2009 and November 2018 in our tertiary centre in Amsterdam, the Netherlands.

RESULTS

The response rate of the questionnaire was 73%, with 52 female respondents (mean age 47.4 ± 12.5 years, mean time since implant 4.6 ± 3.1 years). Postoperative pain exceeded the expectation of 54% of the respondents. Furthermore, 14 out of 49 respondents (29%) expressed an unpleasant feeling during intimate contact with their sexual partner since the implant. Many women (44%) reported daily discomfort caused by their bra and preferred a more cranial and posterior position of the S-ICD generator. Finally, a smaller design of the generator is desired by a great majority (63%) of female S-ICD patients CONCLUSION: Female S-ICD patients experience a variety of issues with a substantial impact on their daily life. Most issues that we identified would benefit from adequate counseling and implanter awareness.

How Patient Perceptions Shape Responses and Outcomes in Inherited Cardiac Conditions

At least one-third of adults living with an inherited cardiac condition report clinically-significant levels of psychological distress. Poorer health-related quality of life compared with population norms is also consistently reported. These outcomes are associated with younger patient age, having an implantable cardioverter defibrillator, and receipt of uncertain clinical test results, and can influence self-management behaviours, such as adherence to potentially critical life-preserving medications. According to the Common Sense Model of Illness, people use information from multiple sources to 'make sense' of their health condition, and how they conceptualise the condition can strongly influence adaptation and coping responses. Previous studies with people with inherited cardiac conditions show that illness perceptions, such as greater perceived consequences and a poorer understanding of the condition, are associated with greater psychological distress and poorer adherence to medication. The Common Sense Model provides one potential framework for identifying patients who may be more vulnerable to adverse health outcomes, and for developing early interventions to reduce the physical and psychosocial burden of these conditions. Interventions based on the Common Sense Model have successfully improved physical and psychosocial outcomes associated with other cardiac conditions, and could be tailored for use with patients with an inherited cardiac condition (ICC).

Preventive or Deferred Ablation of Ventricular Tachycardia in Patients With Ischemic Cardiomyopathy and Implantable Defibrillator (BERLIN VT)

Background:

Catheter ablation for ventricular tachycardia (VT) reduces the recurrence of VT in patients with implantable cardioverter-defibrillators (ICDs). The appropriate timing of VT ablation and its effects on mortality and heart failure progression remain a matter of debate. In patients with life-threatening arrhythmias necessitating ICD implantation, we compared outcomes of preventive VT ablation (undertaken before ICD implantation to prevent ICD shocks for VT) and deferred ablation after 3 ICD shocks for VT.

Methods:

The BERLIN VT study (Preventive Ablation of Ventricular Tachycardia in Patients With Myocardial Infarction) was a prospective, open, parallel, randomized trial performed at 26 centers. Patients with stable ischemic cardiomyopathy, a left ventricular ejection fraction between 30% and 50%, and documented VT were randomly assigned 1:1 to a preventive or deferred ablation strategy. The primary outcome was a composite of all-cause death and unplanned hospitalization for either symptomatic ventricular arrhythmia or worsening heart failure. Secondary outcomes included sustained ventricular tachyarrhythmia and appropriate ICD therapy. We hypothesized that preventive ablation strategy would be superior to deferred ablation strategy in the intention-to-treat population.

Results:

During a mean follow-up of 396±284 days, the primary end point occurred in 25 (32.9%) of 76 patients in the preventive ablation group and 23 (27.7%) of 83 patients in the deferred ablation group (hazard ratio, 1.09 [95% CI, 0.62–1.92]; P =0.77). On the basis of prespecified criteria for interim analyses, the study was terminated early for futility. In the preventive versus deferred ablation group, 6 versus 2 patients died (7.9% versus 2.4%; P =0.18), 8 versus 2 patients were admitted for worsening heart failure (10.4% versus 2.3%; P =0.062), and 15 versus 21 patients were hospitalized for symptomatic ventricular arrhythmia (19.5% versus 25.3%; P =0.27). Among secondary outcomes, the proportions of patients with sustained ventricular tachyarrhythmia (39.7% versus 48.2%; P =0.050) and appropriate ICD therapy (34.2% versus 47.0%; P =0.020) were numerically reduced in the preventive ablation group.

Conclusions:

Preventive VT ablation before ICD implantation did not reduce mortality or hospitalization for arrhythmia or worsening heart failure during 1 year of follow-up compared with the deferred ablation strategy.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02501005.

The prevalence of depression in patients living with implantable cardioverter defibrillator: a systematic review and meta-analysis

Depression is a common disorder in patients with implantable cardioverter defibrillator (ICD). There are a variety of studies estimated the prevalence of depression in these patients. The present study aimed to investigate the prevalence of depression in patients with ICD.

METHODS

In the present study, we conducted a systematic review of studies published in PubMed, Scopus, Web of Science (WoS), Medline, and EMBASE without any time filtration to obtain studies investigated the prevalence of depression in patients with ICD. Search terms consisted of "Implantable Cardioverter Defibrillator(s)" in combination with "depression," "depressive," "prevalence," "implanted cardioverter," "implantable," and "implantable defibrillator."

RESULTS

We identified 15 relevant studies, comprising data from 10,182 patients with ICD from whom 2400 (23.58%) (95% CI, 15.36-31.79) had depression. The results of the subgroup analysis showed that the prevalence of depression among middle-aged patients (28.58% with confidence interval of 95%, 21.51-35.65) was higher than elderly patients (22.23% with confidence interval of 95%, 11.21-33.24) and it was not significantly correlated with the mean age of samples (P = 0.255), sample size (P = 0.686), and the publication date (P = 0.784), although there was a significant correlation between the prevalence of depression and the quality of articles so that the prevalence was decreasing with an increase in the quality (P = 0.046).

CONCLUSION

Around 1 in 4 patients with ICD (23.58%) experiences depression progression after an ICD placement. This prevalence is comparable to that in the general population, and close to that of the patients with common chronic diseases.

Non-invasive Stereotactic Radioablation: A New Option for the Treatment of Ventricular Arrhythmias

Ventricular tachycardia (VT) is associated with significant morbidity and mortality. Radiofrequency catheter ablation can be effective for the treatment of VT but it carries a high rate of recurrence often attributable to insufficient depth of penetration for reaching critical arrhythmogenic substrates. Stereotactic body radioablation (SBRT) is a commonly used technology developed for the non-invasive treatment of solid tumours. Recent evidence suggests that it can also be effective for the treatment of VT. It is a non-invasive procedure and it has the unique advantage of delivering ablative energy to any desired volume within the body to reach sites that are inaccessible with catheter ablation. This article summarises the pre-clinical studies that have formed the evidence base for SBRT in the heart, describes the clinical approaches for SBRT VT ablation and provides perspective on next steps for this new treatment modality.

Multi-morbidity burden, psychological distress, and quality of life in implantable cardioverter defibrillator recipients: Results from a nationwide study

BACKGROUND

The prevalence of multi-morbidity in implantable cardioverter defibrillator (ICD) recipients is approximately 25%. Multi-morbidity is associated with poor health and psychological outcomes in this population and may affect ICD recipients' quality-of-life (QOL). The purpose of this study was to determine the prevalence of psychological distress (anxiety, depressive symptoms, and Type-D personality) in ICD recipients with varying levels of comorbidities, and to examine the association between multi-morbidity burden and QOL in this population.

METHODS

All adults listed in the Swedish ICD and Pacemaker Registry in 2012 with an ICD implanted for at least one year were invited to participate in this study. Binary logistic regression was used to predict QOL using the EQ-5D mean index dichotomized based on median QOL scores. Multi-morbidity burden scores were based on quartile groupings.

RESULTS

A total of 2658 ICD recipients participated in the study (with a mean age of 65, 20.6% female, mean implant duration of 4.7 years, with 35.4% implanted for primary prevention of sudden cardiac arrest). Greater multi-morbidity burden, female sex, not working outside the home, history of ICD shock, negative ICD experience, higher levels of ICD-related concerns, and the presence of anxiety, depression, or Type D personality were associated with worse QOL in ICD recipients. Predictors differed by multi-morbidity burden level.

CONCLUSIONS

Multi-morbidity burden and psychological distress is an essential factor related to QOL. This issue should be discussed with potential ICD recipients prior to implant. Further exploration of increased recognition and treatment of psychological distress in ICD recipients is warranted.

Screening and Management of Depression in Patients With Cardiovascular Disease: JACC State-of-the-Art Review

Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.

Health-Related Quality of Life and Psychological Adjustment of Children and Adolescents with Pacemakers and Implantable Cardioverter Defibrillators: A Systematic Review

The absence of cardiac symptoms, the improved exercise tolerance and the increased life expectancy are the advantages of a successful cardiac device therapy. Nevertheless, the fact of a lifelong device dependency, the inherent possibility of device malfunction and the progression of the underlying heart disease may impact the health-related quality of life (HRQoL) and the psychological adjustment of these individuals. To date, an overview of findings on these topics is lacking. The objective of this study was to evaluate and summarize the current evidence on generic and disease-specific HRQoL and psychological adjustment in paediatric patients with a pacemaker (PM) or an implantable cardioverter defibrillator (ICD). A systematic literature search was conducted using relevant databases and predefined keywords. Study selection was conducted based on predefined inclusion criteria. Fourteen studies were selected which were of varying methodological quality. Overall, the studies indicated that PM/ICD patients themselves and their parents scored lower than healthy controls on generic HRQoL scales and reported similar disease-related HRQoL as patients with severe forms of congenital heart disease. Regarding psychological adjustment outcome, PM recipients and norms were not significantly different with respect to anxiety and depression symptoms, while ICD patients showed more signs of anxiety than depression. HRQoL and psychological health should be considered when setting therapy goals and evaluating medical treatment success. This approach allows an early intervention in patients at risk of maladaptation, which is especially important in the young patient undergoing crucial developmental stages.

Cognitive performance in patients with implantable cardioverter defibrillators: Associations with objective sleep duration, age and anxiety

Sleep disturbance and anxiety are highly prevalent in patients with implantable cardiac defibrillators (ICDs). There is limited research, however, on the associations between cognitive performance and sleep parameters, age and anxiety. Forty-one patients with ICDs and self-reported sleep disturbance completed 14 days of actigraphy (M_age  = 60.3, SD = 12.3) measuring total sleep time (TST), and a computerized cognitive test battery measuring processing speed and attention (i.e. simple reaction time and symbol digit modality task [SDMT]) and executive function (i.e. flanker task, letter series task and N-back task). Multiple regressions determined whether independent effects of TST, age and anxiety, as well as interactive effects of TST and age, predicted cognitive performance. TST predicted performance on two tasks of executive function (i.e. letter series and N-back task), as well as an attentional vigilance and processing speed task (i.e. SDMT), and this did not depend on patient age. On letter series, N-back and SDMT, longer TST predicted better performance. Increasing age was a predictor of worse performance on SDMT and flanker tasks. No other predictors were associated with task performance. Results show that sleep duration, not anxiety, may be an important predictor of higher-order cognitive functioning and lower-order tasks measuring processing speed and attention in ICD patients, with longer sleep duration showing greater benefit for performance.

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC)

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

[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.

Psychometric Testing of the Emotional Responses Post Implantable Cardioverter Defibrillator Scale

BACKGROUND AND PURPOSE

The implantable cardioverter (ICD) is the mainstay of treatment for patients at risk for and those who have had life threatening arrhythmias. The negative emotional responses are important for clinicians to identify. The purpose of this study was to develop and evaluate the psychometric properties of The Emotional Responses Post Implantable Cardioverter Defibrillator Scale among patients with ICD.

METHODS

This study was completed in phases; content validity, construct validity, internal consistency, reliability of the instrument and test-retest reliability.

RESULTS

The 3 factors are Factor 1, Depressive Symptoms; Factor 2, Anxiety Symptoms; and Factor 3, Fear of the Device. The overall coefficient for the total set of items was .85. Coefficients of the three factors ranged from .80 to .85.

CONCLUSION

This study provides evidence to support the content, construct validity, and reliability of this scale.

Factors associated with anxiety and depression among patients with implantable cardioverter defibrillator

AIMS AND OBJECTIVES

To identify factors associated with anxiety and depression of patients with implantable cardioverter defibrillators.

BACKGROUND

Implantable cardioverter defibrillator is effective to increase survival from life-threatening arrhythmias, but it lowers health-related quality of life. Anxiety and depression had significant negative association with health-related quality of life. However, knowledge about factors associated with these two negative emotions in this specific population is inadequate.

DESIGN

A cross-sectional descriptive design was conducted. Secondary analysis was performed to address the aim.

METHODS

A convenience sampling of patients with implantable cardioverter defibrillators was performed. Anxiety and depression were measured by the Hospital Anxiety and Depression Scale through face-to-face interview.

RESULTS

Stepwise multivariable regression results showed that older age (aged 60-69 and ≥70: B = 2·08 and 3·31, p = 0·039 and <0·001), self-care dependence (B = 3·47, p < 0·001), being married (B = -2·21, p = 0·004) and having ischaemic heart disease (B = -1·80, p = 0·008) were significantly associated with depression. However, there was no significant factor associated with anxiety.

CONCLUSIONS

Factors associated with depression among patients with implantable cardioverter defibrillator are identified. Older age (aged ≥60) and more self-care dependence have positive, but being married and having ischaemic heart disease have negative association with depression. Strategies to reduce psychological distress are highlighted.

RELEVANCE TO CLINICAL PRACTICE

The study findings direct the care to improve health-related quality of life by reducing and controlling vulnerabilities arising from depression. Patients who are older people (≥aged 60) and more self-care dependent perceive higher depression. Nursing strategies are suggested to reduce depression especially for those who are older people and more self-care dependent. Early screening is essential to provide immediate care for reducing vulnerabilities arising from depression. Performing comprehensive assessment for self-care ability and providing adequate assistance are crucial. Family involvement may reduce depression through providing physical and psychosocial support.

Toward a More Efficient Implementation of Antifibrillation Pacing

We devise a methodology to determine an optimal pattern of inputs to synchronize firing patterns of cardiac cells which only requires the ability to measure action potential durations in individual cells. In numerical bidomain simulations, the resulting synchronizing inputs are shown to terminate spiral waves with a higher probability than comparable inputs that do not synchronize the cells as strongly. These results suggest that designing stimuli which promote synchronization in cardiac tissue could improve the success rate of defibrillation, and point towards novel strategies for optimizing antifibrillation pacing.

Left Ventricular Ejection Fraction Predicts Severity of Posttraumatic Stress Disorder in Patients With Implantable Cardioverter-Defibrillators

BACKGROUND

Implantable cardioverter-defibrillators (ICD) have provided effective therapy for fatal arrhythmia. However, ICD patients are known to develop psychological problems, such as posttraumatic stress disorder (PTSD), if they have experienced potentially fatal arrhythmia and ICD shocks. Little is known about the factors influencing PTSD in ICD patients.

HYPOTHESIS

Echocardiographic cardiac-function parameters might relate to psychological problems, especially PTSD, in ICD patients.

METHODS

A total of 128 outpatients with ICD implantation completed the Impact of Event Scale Revised (IES-R) questionnaire as a measurement of PTSD. Demographic and clinical characteristic data were collected from medical records.

RESULTS

The mean age of the ICD patients was 59 ± 16 years; 103 were male; and the mean left ventricular ejection fraction (LVEF) by echocardiography was 52.4% ± 18.3%. In the ICD patients, female sex and impaired LVEF were related to lower IES-R scores or led to PTSD (P = 0.01 and P = 0.03, respectively). Impaired LVEF also worsened 2 symptoms of PTSD, intrusion (P = 0.02) and hyperarousal (P = 0.03). In patients with LVEF <35%, there was a significant negative correlation between LVEF level and IES-R score (P = 0.045).

CONCLUSIONS

This study showed that LVEF was related to the severity of PTSD, especially in the ICD patients with LVEF of <35%. We should pay more attention to ICD patients with severely impaired left ventricular function to prevent psychological problems.

Knowledge of Implantable Cardioverter Defibrillator Purpose and Function Among Nurses in the United States

BACKGROUND

Nurses play a crucial role in patient education and adaptation to having an implantable cardioverter defibrillator (ICD).

OBJECTIVE

The aim of this study was to assess cardiology nurses' knowledge and confidence in providing education and support to ICD recipients.

METHODS

A cross-sectional descriptive survey was used to assess nurses' knowledge and experience caring for ICD recipients in 2 academic medical centers in the Pacific Northwest, using an instrument developed in 2004 in the United Kingdom.

RESULTS

Nurses (N = 74) worked on cardiology units or clinics, primarily held a baccalaureate degree or higher (85%), and had 16 years or more of nursing experience and 6 to 10 years of cardiology experience. The overall average knowledge score was 77%, with knowledge about modern ICD technology averaging 55%. Nurses' confidence, using 10-point scale, in preparing patients to receive an ICD implant was 6.32 ± 2.56, for preparing patients for discharge was 6.14 ± 2.43, and for providing education about ICD shocks was 6.63 ± 2.50. Nurses were most knowledgeable about factors that affect patient retention of knowledge and ICD-related environmental hazards. Nurses lacked knowledge about the basic ICD components, purpose of cardiac resynchronization, and dual-chamber ICDs. Factors associated with higher knowledge scores included past experience caring for a patient with an ICD and working in an electrophysiology outpatient clinic.

CONCLUSIONS

The ICD knowledge of US nurses in 2015 was similar to that reported in the United Kingdom in 2004, with limited knowledge about the complexities of modern ICD devices. Such deficits in knowledge may affect the quality of education provided to ICD recipients in preparing them to live safely with an ICD.

Positive Psychotherapy to Improve Autonomic Function and Mood in ICD Patients (PAM-ICD): Rationale and Design of an RCT Currently Underway

BACKGROUND

Improving mental and physical health of patients with implantable cardioverter defibrillators (ICD) is critical because this group is at high risk for ventricular arrhythmias and sudden death and depressed or anxious cardiovascular disease (CVD) patients appear to be at even higher risk for mortality compared to nondepressed or nonanxious CVD patients. Further, autonomic dysfunction is present in these patients, and negative emotions and arrhythmias form a downward spiral further worsening mood, well-being, and cardiovascular health. Much research demonstrates that positive emotion is related to health benefits, improved physiology, and increased survival.

METHODS AND RESULTS

This is a two-arm randomized controlled trial aiming to recruit 60 adult ICD patients comparing 12 individually delivered, weekly sessions of: (1) a positive emotion-focused cognitive-behavioral therapy (Quality of Life Therapy [QOLT]), and (2) Heart Healthy Education. Autonomic functioning, heart rhythm indices, and psychosocial health are measured at baseline, 3 months, and 9 months. The first goal is feasibility and acceptability, with the primary outcome being arrhythmic event frequency data.

CONCLUSION

This study is designed to test whether QOLT produces changes in mood, quality of life/well-being, autonomic function, and arrhythmic and ICD therapy event rates. This feasibility trial is a foundational step for the next trial of QOLT to help determine whether a 3-month QOLT trial can reduce arrhythmias occurrences among ICD patients, and examine a mechanism of autonomic functioning. This study may help to develop and implement new medical or psychological therapies for ICD patients.

Tetanizing prepulse: A novel strategy to mitigate implantable cardioverter-defibrillator shock-related pain

BACKGROUND

Skeletal muscle activation has been implicated as the source of pain associated with implantable cardioverter-defibrillator shocks. We hypothesized that the skeletal muscle response to defibrillatory shocks could be attenuated with a tetanizing prepulse immediately before biphasic shock delivery.

OBJECTIVE

The purpose of this study was to test the ability of tetanizing prepulses to reduce the skeletal muscle activation associated with defibrillation.

METHODS

Seven adult pigs were studied. A left ventricular coil and subcutaneous dummy can in the right thorax were used to deliver either pure biphasic waveforms or test waveforms consisting of a tetanizing pulse of high-frequency alternating current (HFAC) ramped to an amplitude of 5-100 V over 0.25-1 second, immediately followed by a biphasic shock of approximately 9 J (ramped HFAC and biphasic [rHFAC+B]). We used limb acceleration and rate of force development as surrogate measures of pain. Test and control waveforms were delivered in sinus rhythm and induced ventricular fibrillation to test defibrillation efficacy.

RESULTS

Defibrillation threshold energy was indistinguishable between rHFAC+B and pure biphasic shocks. Peak acceleration and rate of force development were reduced by 72% ± 7% and 71% ± 22%, respectively, with a 25-V, 1-second rHFAC+B waveform compared with pure biphasic shocks. Notably, rHFAC+B with a 9-J biphasic shock produced significantly less skeletal muscle activation than a 0.1-J pure biphasic shock.

CONCLUSION

A putative source of implantable cardioverter-defibrillator shock-related pain can be mitigated using a tetanizing prepulse followed by biphasic shock. Human studies will be required to assess true pain reduction with this approach.

Gender Disparities in Symptoms of Anxiety, Depression, and Quality of Life in Defibrillator Recipients

BACKGROUND

Most patients cope well with an implantable cardioverter defibrillator (ICD), but psychological distress and ICD-related concerns have been reported in about 20% of ICD recipients. Many previous studies have not distinguished between genders.

METHODS

In this nationwide study we compared quality of life, anxiety, and depression symptoms between the genders in ICD recipients, and determined predictors of each of these variables in men and women. All adult Swedish ICD recipients were invited by mail to participate and 2,771 patients (66 ± 12 years) completed standardized measures of quality of life, symptoms of anxiety, and depression. Time since implantation ranged from 1 year to 23 years with a mean of 4.7 ± 3.9.

RESULTS

Women reported worse quality of life (mean index 0.790 vs 0.825) and higher prevalence of anxiety (20.5% vs 14.7%) than did men (P < 0.001 for both comparisons), while there were no differences in symptoms of depression (8.8% vs 8.2%).

CONCLUSIONS

Most ICD recipients report a good quality of life, without emotional distress, but among the minority with distress, women fare worse than men.

Influence of primary and secondary prevention indications on anxiety about the implantable cardioverter-defibrillator

Background

Implantable cardioverter-defibrillators (ICDs) have been established for primary and secondary prevention of fatal arrhythmias. However, little is known about the influence of ICD indications on quality of life (QOL) and psychological disturbances. This study aimed to examine whether there were differences in QOL and psychological distress in patients that have an ICD for primary or secondary prevention of fatal arrhythmias.

Methods

A multicenter survey of 179 consecutive outpatients (29.1% primary prevention) with ICD implantations completed the Short Form-8 (SF-8), Beck Depression Inventory (BDI), Impact of Event Scale-Revised (IES-R), State-Trait Anxiety Inventory (STAI), and Worries about ICD (WAICD).

Results

Patients with an ICD for primary prevention had a higher trait anxiety score and worries about ICD score than patients with an ICD for secondary prevention (41.7±12.4 vs. 34.7±12.3, p=0.001 and 39.6±18.0 vs. 30.0±18.9, p=0.002, respectively), even after adjusting for demographic and clinical characteristics. In multivariable analysis of variance, primary prevention ICD recipients reported a poorer QOL on the vitality subscale of the SF-8.

Conclusions

In our study population, which mostly consisted of New York Heart Association (NYHA) class I and II subjects, primary prevention ICD recipients were more prone to experience worries about their ICD, anxiety, and a poorer QOL compared to secondary prevention ICD recipients. In clinical practice, primary prevention ICD patients should be closely monitored. If warranted, they should be offered psychological intervention, as anxiety and low QOL were predictors of mortality.

A pilot study of a mindfulness based stress reduction program in adolescents with implantable cardioverter defibrillators or pacemakers

Adolescents with implantable cardioverter defibrillators (ICDs) or pacemakers (PMs) face unique challenges that can cause psychosocial distress. Psychosocial interventions are effective for adults with cardiac devices and could potentially impact adolescents' adjustment to these devices. Mindfulness Based Stress Reduction (MBSR) is a structured psycho-educational program that includes meditation, yoga, and group support and has been studied extensively among adults. This study examined the feasibility of the MBSR program for adolescents with ICDs/PMs, a population previously unexamined in the research literature. The participants completed measures of anxiety and depression (Hospital Anxiety and Depression Scale) and coping (Responses to Stress Questionnaire) at baseline and after the six-session MBSR intervention. Mean age of the cohort (n = 10) was 15 ± 3 years, 6 were male, 6 had a PM, and 4 had an ICD. Feasibility was demonstrated by successful recruitment of 10 participants, 100 % participation and completion. Anxiety decreased significantly following the intervention, with a large effect size, t[9] = 3.67, p < .01, ŋ (2) = .59. Anxiety frequency decreased from baseline to post-intervention (Fisher's exact test p = .024), and 90 % of participants reported decreased anxiety scores post-intervention. Coping skills related negatively to anxiety (r = -.65, p = .04) and depression (r = -.88, p = .001). Post-intervention, the group independently formed their own Facebook group and requested to continue meeting monthly. Although generalizability is limited due to the small sample size, this successful pilot study paves the way for larger studies to examine the efficacy of MBSR interventions in adolescents with high-risk cardiac diagnoses.