Recipients' of implanted cardioverter-defibrillators actual and perceived adaptation: a review of the literature

Experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to synthesize the best available qualitative evidence on the everyday life experiences of adults living with an implantable cardioverter defibrillator for cardiovascular disease.

INTRODUCTION

Cardiovascular disease is a rising concern worldwide. The efficacy of the implantable cardioverter defibrillator as a successful treatment for cardiovascular disease has been well documented. Research suggests that living with an implantable cardioverter defibrillator is complex and can cause substantial psychosocial distress that can manifest itself at various intervals over time. The first step to developing evidence-based recommendations related to the management of implantable cardioverter defibrillator-related distress is a critical appraisal and synthesis of relevant literature to gain a more comprehensive understanding of this phenomenon.

INCLUSION CRITERIA

The participants of interest were adults 18 years or older who had an implantable cardioverter defibrillator for the management of cardiovascular disease (e.g. ischemic heart disease, angina, cardiomyopathy, myocardial infarction, congenital defect, arrhythmias, heart failure). The phenomenon of interest was the everyday life experience of adults living with an implantable cardioverter defibrillator. The review considered all qualitative research related to the phenomenon of interest.

METHODS

Key databases searched were PubMed, CINAHL, PsycINFO, Embase, International Bibliography of the Social Sciences, Sociological Abstracts, OpenGrey, MedNar, ProQuest Dissertations and Theses Global, Google, and Google Scholar. Published and unpublished papers and articles from 1990 to July 2018 were included in the search. The JBI approach to critical appraisal, study selection, data extraction, and synthesis for qualitative research was used throughout the review.

RESULTS

Twenty-seven papers were included in the review that yielded 143 findings and 13 categories. The methodological quality of the 27 included studies was moderate to strong. Based on ConQual scores, confidence in the synthesized findings was moderate. From this, three synthesized findings were extracted: i) living under the shadow of uncertainty, ii) orchestrating a new normal, and iii) crafting a positive vision for the future.

CONCLUSIONS

Evidence suggests that while implantable cardioverter defibrillator recipients do experience psychosocial distress, they gradually positively embrace the device as part of their everyday norm. Recommendations for practice and education point to the further development of best practice guidelines for implantable cardioverter defibrillator management, continuing education programs for health care providers, and strategies to support implantable cardioverter defibrillator recipients and their families to cope with the device. Research that examines onset, level, and duration of implantable cardioverter defibrillator psychosocial distress is needed to target specific interventions reflective of this population's needs. While findings suggest the experiences of women living with an implantable cardioverter defibrillator are similar to men, the low number of women in included studies limits the strength of this conclusion.

The impact of transvenous cardioverter-defibrillator implantation on quality of life, depression and optimism in dialysis patients: report on the secondary outcome of QOL in the randomized controlled ICD2 trial

RATIONALE

The impact of prophylactic implantable cardioverter-defibrillator (ICD) implantation on the psychological well-being of patients on dialysis is unknown.

OBJECTIVE

We aimed to identify the effect of primary ICD implantation on quality of life (QoL), mood and dispositional optimism in patients undergoing dialysis.

METHODS AND RESULTS

We performed a prespecified subanalysis of the randomized controlled ICD2 trial. In total, 177 patients on chronic dialysis, with an age of 55-81 years, and a left ventricular ejection fraction of ≥ 35%, were included in the per-protocol analysis. Eighty patients received an ICD for primary prevention, and 91 patients received standard care. The Short Form-36 (SF-36), Geriatric Depression Scale-15 (GDS-15), Revised Life Orientation Test (LOT-R) questionnaires were administered prior to ICD implantation (T0), and at 1-year follow-up (T1) to assess QoL, depression and optimism, respectively. The patients were predominantly male (76.0%), with a median age of 67 years. Hemodialysis was the predominant mode of dialysis (70.2%). The GDS-15 score difference (T1 - T0) was 0.5 (2.1) in the ICD group compared with 0.3 (2.2) in the control group (mean difference - 0.3; 95% CI - 1.1 to 0.6; P = 0.58). The LOT-R score difference was - 0.2 (4.1) in the ICD group compared with - 1.5 (4.0) in the control group (mean difference - 1.1 (0.8); 95% CI - 2.6 to 0.4; P = 0.17). The mean difference scores of all subscales of the SF-36 were not significantly different between randomization groups.

CONCLUSIONS

In our population of patients on dialysis, ICD implantation did not affect QoL, mood or dispositional optimism significantly during 1-year follow-up.

CLINICAL TRIAL REGISTRATION

Unique identifier: ISRCTN20479861. http://www.controlled-trials.com .

"Those Plates That Save Me": Experiences of Italian Patients With Implantable Cardioverter Defibrillator

This study aimed to investigate and understand the experiences and feelings lived by people with an ICD. Qualitative study, semi-structured interviews were conducted with a sample of 16 patients, during the annual follow-up. A hermeneutical analysis of the interviews was carried out to identify the themes. Four main themes were classified: "My heart falls asleep," highlighting a reduced awareness of the pathology and ICD installation; "But what is this thing. . .?" underlining the lack of information and fears related to the device and its functioning; "I cannot hug the microwave" which describes the changes brought about by the surgery; "And with this one I am alright for the rest of my life", involving hopes and life expectations. This study highlighted the patients' need for major support from health professionals while processing their new life conditions.

[Quality of life in patients with implantable cardioverter-defibrillator from a salutogenic perspective : A qualitative study in cardiologic health service research]

BACKGROUND

Evidence on disease-related quality of life (DRQoL) of patients with implantable cardioverter-defibrillators (ICDs) has been described heterogeneously. Disease-specific measures of DRQoL in ICD patients are lacking.

OBJECTIVES

The aim of this study was to gain a broader understanding of long-term DRQoL in ICD patients. Special focus was placed on stressors and cognitive management strategies in everyday life.

METHODS

Data assessment was performed via semistructured, guideline-based interviews. The monocentric qualitative study included 10 ICD patients with primary and secondary prophylactic indication and 3 cardiologists. The qualitative analysis used the salutogenesis model (Antonovsky) as a framework.

RESULTS

The interviews show that most patients do not experience a prominent limitation in their quality of life through the ICD. We found that patients focus on their individual coping strategies to handle the ICD indication with a sense of coherence, aiming at understanding their situation and giving it meaning. Whether the DRQoL is modified positively or negatively after ICD implantation depends on individual factors of resilience and factors of coherence.

CONCLUSIONS

We established a salutogenic model for the assessment of DRQoL in patients with ICDs. A stable DRQoL on ICD implantation and follow-up could be achieved if patients at high risk (small sense of coherence and reduced resilience) are identified and their individual lifestyles are taken into account.

Exploring the patients’ experiences of living with a subcutaneous implantable cardioverter defibrillator

Background:

The implantable cardioverter defibrillator provides effective treatment for the prevention of sudden cardiac arrest but significant risks associated with transvenous implantation persist. The subcutaneous implantable cardioverter defibrillator has proven to be an alternative and innovative treatment option for select patients to mitigate these risks. Obtaining the patients’ perspectives can provide clinicians with essential information to guide implant selection, procedural decision-making, and support patient management. Conventional implantable cardioverter defibrillator patients have reported shock-related anxiety, fear, insufficient education, and challenges adapting to physical and psychological changes. Little evidence exists to determine whether differences between the subcutaneous implantable cardioverter defibrillator and conventional implantable cardioverter defibrillator allow for the transferability of our current knowledge to the care and management of this population.

Aims:

The purpose of this study was to explore patients’ experiences of living with a subcutaneous implantable cardioverter defibrillator including the decision-making process, implant, and follow-up care processes.

Methods:

Using an exploratory qualitative approach, semi-structured interviews were conducted by telephone with 15 participants who underwent subcutaneous implantable cardioverter defibrillator implant.

Results:

Analysis revealed five main themes: (a) influences on decision-making; (b) unmet education needs; (c) physical impact; (d) psychological impact; and (e) recommendations.

Conclusion:

As a new technology, little knowledge of the subcutaneous implantable cardioverter defibrillator exists outside of the tertiary implanting sites, therefore developing new strategies to increase learning and dissemination is essential. Although similarities exist in our findings to those of conventional implantable cardioverter defibrillators, there are significant differences in the decision-making process and physical impact which require individualized care planning and development of strategies to provide a patient-centered approach to care.

Embodying a New Meaning of Being At Risk: Living With an Implantable Cardioverter Defibrillator for Arrhythmogenic Right Ventricular Cardiomyopathy

Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia (ARVC/D) is a genetic condition that can cause fatal arrhythmias. The implantable cardioverter defibrillation (ICD) is a primary treatment for ARVC/D. Using a grounded theory approach, this study examines the experiences of 15 individuals living with an ICD. The ability to cope with and adjust to having an ICD is influenced by the acceptance of the ICD as something needed to survive, an understanding of the ICD's function, existing support networks, and ones' ability to manage everyday challenges. Coping well requires reshaping ideas about the meaning of being at risk and understanding how the ICD fits into that changing personal risk narrative. A thorough understanding of the unique needs of individuals with ARVC/D and of the specific factors contributing to the psychosocial distress related to having an ICD (vs. having the disease itself) is needed. Nurses must be prepared to provide ongoing support and education to this population.

The Challenges of Living With an Implantable Cardioverter Defibrillator: A Qualitative Study

BACKGROUND

Dysrhythmia is one of the most common causes of sudden cardiac death worldwide. An implantable cardioverter defibrillator is the most effective method of treatment for dysrhythmias causing cardiac arrest. However, living with an implantable cardioverter defibrillator is associated with challenges such as fear, anxiety, and depression.

OBJECTIVES

The purpose of this study was to identify the challenges of living with an implantable cardioverter defibrillator.

PATIENTS AND METHODS

In this qualitative study, an interpretive phenomenological approach was used, with thirteen participants (seven men and six women) between the ages of 21 and 70 years old (mean = 58.15, SD = 14.4). The duration of having an implantable cardioverter defibrillator was 1 - 120 months (mean = 23.15, SD = 33.31). Maximum variation sampling was used to purposefully select the participants from the governmental Imam Khomeini hospital in Tehran, Iran, between May and October of 2013. Semi-structured interviews were conducted for 30 to 45 minutes, and Van Manen's six-step method was used in this study.

RESULTS

The challenges of living with an implantable cardioverter defibrillator include: living with fear, concerns about the future, concerns about device malfunction, fearing death during the shock, pain due to the shock, loss of control, the cost of the device, and the lifestyle limitations.

CONCLUSIONS

Patients who live with implantable cardioverter defibrillators face many concerns and challenges. Therefore, the role of nurses in teaching patients before and after implementation is very important.

Iranian Patients' Experiences of the Internal Cardioverter Defibrillator Device Shocks: a Qualitative Study

Introduction: Implantable Cardioverter Defibrillator (ICD) is a valuable treatment for the patients at risk of sudden cardiac death. In this method, after diagnosis of pathological cardiac rhythms, shock is automatically applied to normalize the rhythms. Shock is discharged when the patients are conscious, but the patients’ experiences of shock have remained unknown. Thus, this study aimed to identify and describe the patients’ experiences of shocks received from ICD.

Methods: The present qualitative study was conducted through thematic analysis and semi-structured interviews on 9 patients mean age 41.55 (1.57) with ICD from November 2013 to July 2014. Data analysis was also performed simultaneously using constant comparative analysis.

Results: In this study, two main themes, namely "with a parachute for life" and "Faced with nuisance", were obtained representing the patients’ experiences regarding ICD shock. With a parachute for life included subthemes, such as "Rebirth", "Comforter and healing", and "Life assurance". In addition, "Faced with nuisance" consisted of 2 subthemes of "Discomfort in moments of shock" and "Displeasure after shock".

Conclusion: This study provided a basis for evaluation of patients nursing after discharge. By identification of the patients’ experiences regarding shock, the present study can help the professional health staff to efficiently play their roles and provide patients with holistic care. It can also be effective in designing behavioral and cognitive interventional programs to change the patients’ attitude and promote their adaptation with their conditions.

Perceived Benefits of Implantable Cardioverter Defibrillator Implantation among Heart Failure Patients and Its Relation to Quality of Life: A Cross-Sectional Study

Introduction

Patients with heart failure (HF) and implantable cardioverter defibrillators (ICDs) may misunderstand the indication of ICDs due to unsatisfactory information. The goal of this study is to evaluate the patient perspective of ICD indication and its relation to quality of life, as well as to identify probable communication gaps between doctors and ICD receivers.

Methods

A total of 119 patients with HF who were implanted with a single-chamber ICD were evaluated in outpatient clinics. Patients with cardiac resynchronization therapy-defibrillators were not included in the study. In a questionnaire, patients were asked about the indication of the ICD procedure and classified according to the perceived benefits.

Results

This study showed that most of the patients (n = 92, 77.3%) believed that ICD was implanted for improvement of heart dysfunction or for symptom relief. According to the perceived benefit groups, physical function, general health, vitality, and role physical scores were significantly lower in the symptom relief group (p < 0.05).

Conclusion

Patients with HF and ICD mostly believed that the cardioverter defibrillator implanted for improving heart function or symptom relief. Doctors play a significant role when a patient is first referred for ICD because less-informed patients are more prone to misunderstand the procedure’s benefits. Moreover, unfulfilled expectations may lead to loss of confidence in applied therapies and result in poor health outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s40119-015-0049-8) contains supplementary material, which is available to authorized users.

What value is the CINAHL database when searching for systematic reviews of qualitative studies?

BACKGROUND

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) is generally thought to be a good source to search when conducting a review of qualitative evidence. Case studies have suggested that using CINAHL could be essential for reviews of qualitative studies covering topics in the nursing field, but it is unclear whether this can be extended more generally to reviews of qualitative studies in other topic areas.

METHODS

We carried out a retrospective analysis of a sample of systematic reviews of qualitative studies to investigate CINAHL's potential contribution to identifying the evidence. In particular, we planned to identify the percentage of included studies available in CINAHL and the percentage of the included studies unique to the CINAHL database. After screening 58 qualitative systematic reviews identified from the Database of Abstracts of Reviews of Effects (DARE), we created a sample set of 43 reviews covering a range of topics including patient experience of both illnesses and interventions.

RESULTS

For all 43 reviews (21 %) in our sample, we found that some of the included studies were available in CINAHL. For nine of these reviews, all the studies that had been included in the final synthesis were available in the CINAHL database, so it could have been possible to identify all the included studies using just this one database, while for an additional 21 reviews (49 %), 80 % or more of the included studies were available in CINAHL. Consequently, for a total of 30 reviews, or 70 % of our sample, 80 % or more of the studies could be identified using CINAHL alone. 11 reviews, where we were able to recheck all the databases used by the original review authors, had included a study that was uniquely identified from the CINAHL database. The median % of unique studies was 9.09%; while the range had a lowest value of 5.0% to the highest value of 33.0%. [corrected].

CONCLUSIONS

Assuming a rigorous search strategy was used and the records sought were accurately indexed, we could expect CINAHL to be a good source of primary studies for qualitative evidence syntheses. While we found some indication that CINAHL had the potential to provide unique studies for systematic reviews, we could only fully test this on a limited number of reviews, so we are less confident about this finding.

Psychosocial and cardiac outcomes of yoga for ICD patients: a randomized clinical control trial

BACKGROUND

Because as many as 46% of implantable cardioverter defibrillator (ICD) patients experience clinical symptoms of shock anxiety, this randomized controlled study evaluated the efficacy of adapted yoga (vs usual care) in reducing clinical psychosocial risks shown to impact morbidity and mortality in ICD recipients.

METHODS

Forty-six participants were randomized to a control group or an 8-week adapted yoga group that followed a standardized protocol with weekly classes and home practice. Medical and psychosocial data were collected at baseline and follow-up, then compared and analyzed.

RESULTS

Total shock anxiety decreased for the yoga group and increased for the control group, t(4.43, 36), P < 0.0001, with significant differences between these changes. Similarly, consequential anxiety decreased for the yoga group but increased for the control group t(2.86,36) P = 0.007. Compared to the control, the yoga group had greater overall self-compassion, t(-2.84,37), P = 0.007, and greater mindfulness, t(-2.10,37) P = 0.04, at the end of the study. Exploratory analyses utilizing a linear model (R(2) = 0.98) of observed device-treated ventricular (DTV) events revealed that the expected number of DTV events in the yoga group was significantly lower than in the control group (P < 0.0001). Compared to the control, the yoga group had a 32% lower risk of experiencing device-related firings at end of follow-up.

CONCLUSIONS

Our study demonstrated psychosocial benefits from a program of adapted yoga (vs usual care) for ICD recipients. These data support continued research to better understand the role of complementary medicine to address ICD-specific stress in cardiac outcomes.

Sexuality and chronic illness

Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice.

Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP)

After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.

Remote monitoring and follow-up of cardiovascular implantable electronic devices in the Netherlands : An expert consensus report of the Netherlands Society of Cardiology

Remote monitoring of cardiac implanted electronic devices (CIED: pacemaker, cardiac resynchronisation therapy device and implantable cardioverter defibrillator) has been developed for technical control and follow-up using transtelephonic data transmission. In addition, automatic or patient-triggered alerts are sent to the cardiologist or allied professional who can respond if necessary with various interventions. The advantage of remote monitoring appears obvious in impending CIED failures and suspected symptoms but is less likely in routine follow-up of CIED. For this follow-up the indications, quality of care, cost-effectiveneness and patient satisfaction have to be determined before remote CIED monitoring can be applied in daily practice. Nevertheless remote CIED monitoring is expanding rapidly in the Netherlands without professional agreements about methodology, responsibilities of all the parties involved and that of the device patient, and reimbursement. The purpose of this consensus document on remote CIED monitoring and follow-up is to lay the base for a nationwide, uniform implementation in the Netherlands. This report describes the technical communication, current indications, benefits and limitations of remote CIED monitoring and follow-up, the role of the patient and device manufacturer, and costs and reimbursement. The view of cardiology experts and of other disciplines in conjunction with literature was incorporated in a preliminary series of recommendations. In addition, an overview of the questions related to remote CIED monitoring that need to be answered is given. This consensus document can be used for future guidelines for the Dutch profession.