Predictors of quality of life in patients with implantable cardioverter defibrillators

The Impact of Cardiac Devices on Patients’ Quality of Life—A Systematic Review and Meta-Analysis

The implantation of cardiac devices significantly reduces morbidity and mortality in patients with cardiac arrhythmias. Arrhythmias as well as therapy delivered by the device may impact quality of life of patients concerned considerably. Therefore we aimed at conducting a systematic search and meta-analysis of trials examining the impact of the implantation of cardiac devices, namely implantable cardioverter-defibrillators (ICD), pacemakers and left-ventricular assist devices (LVAD) on quality of life. After pre-registering the trial with the PROSPERO database, we searched Medline, PsycINFO, Web of Science and the Cochrane databases for relevant publications. Study quality was assessed by two independent reviewers using standardized protocols. A total of 37 trials met our inclusion criteria. Of these, 31 trials were cohort trials while 6 trials used a randomized controlled design. We found large pre-post effect sizes for positive associations between quality of life and all types of devices. The effect sizes for LVAD, pacemaker and ICD patients were g = 1.64, g = 1.32 and g = 0.64, respectively. There was a lack of trials examining the effect of implantation on quality of life relative to control conditions. Trials assessing quality of life in patients with cardiac devices are still scarce. Yet, the existing data suggest beneficial effects of cardiac devices on quality of life. We recommend that clinical trials on cardiac devices routinely assess quality of life or other parameters of psychological well-being as a decisive study endpoint. Furthermore, improvements in psychological well-being should influence decisions about implantations of cardiac devices and be part of patient education and may impact shared decision-making.

Quality of life of cardiac outpatients with and without psychiatric disorders: a cross-sectional study

Background

The study aims to measure the quality of life (QOL) for cardiac outpatients with psychiatric disorders (CPP) in comparison to cardiac outpatients without psychiatric disorders (CPOP). A semi-structured interview was performed for consecutive cardiac outpatients. Psychiatric diagnoses were confirmed using the mini-international neuropsychiatric interview (MINI). The QOL was measured by the World Health Organization quality of life (WHOQOL-BREF).

Results

Out of the 343 enrolled patients, 93 (27.1%) patients were found to have psychiatric disorders. The WHO-BREF score of QOL was 4.25 ± 0.85. The CPP were found to have statistically significant lower scores in QOL than CPOP in all the WHOQOL-BREF domains. Particularly, the domain of psychological health showed the highest difference between the two groups (76.9 vs. 87.8, P < 0.001), whereas the environment domain showed the lowest difference between them (80.2 vs. 87.9, P < 0.001). Within each QOL domain, patients with congestive heart failure and psychiatric disorders showed the lowest QOL in both the physical domain (51.4 vs. 71.3, P < 0.02) and the social domain (64.7 vs. 81.9, P < 0.05), while patients with vulvular heart disease and psychiatric disorders showed the lowest QOL in the psychological domain (74.6 vs. 85.7, P < 0.001) and patients with arrhythmias and psychiatric disorders in the environment domain (80 vs. 86.2, P < 0.02).

Conclusions

The QOL of CPP were found to have poorer QOL than CPOP. The magnitude of difference in QOL was the highest in the psychological health domain and the lowest in the environment domain.

Profiles of partner health linked to a partner-focused intervention following patient initial implantable cardioverter defibrillator (ICD)

This study examined differential responses among partners who participated in a RCT designed to compare two social cognitive theory interventions, one designed for patients only (P-only) and one for patients and their intimate partners (P + P). The interventions were delivered following the patient receiving an initial ICD implant. Partner health outcomes were examined longitudinally from baseline at hospital discharge to 3, 6, and 12 months. Outcomes included 6 measures: partner physical and mental health status (Short-Form-36 PCS and MCS), depression (Patient Health Questionnaire-9), anxiety (State-Trait Anxiety Inventory), caregiver burden (Oberst Caregiver Burden Scale), and self-efficacy in ICD management (Sudden Cardiac Arrest Self-efficacy scale). Growth mixture and mixed effect modeling were used to identify and compare trajectories of 6 health outcomes within the P-only and P + P arms of the study. Partners (n = 301) were on average 62 years old, female (74.1%) and Caucasian (83.4%), with few co-morbidities (mean Charlson Co-morbidity index, 0.72 ± 1.1). Two types of profiles were observed for P-only and P + P, one profile where patterns of health outcomes were generally better across 12 months and one with outcome patterns that were generally worse across time. For PCS, no significant partner differences were observed between P-only or P + P in either the better (p = 0.067) or the worse (p = 0.129) profile types. Compared to P-only, partners in the worse profile improved significantly over 12 months in MCS (p = 0.006), caregiver burden P + P (p = 0.004) and self-efficacy P + P (p = 0.041). Compared to P-only, P + P partners in the low anxiety profile improved significantly (p = 0.001) at 3 months. Partners with more psychosocial distress at hospital discharge benefited most from the P + P intervention. Among partners with generally low levels of anxiety, those in the P + P intervention compared to P-only showed greater improvement in anxiety over 12 months.

Patient reported outcomes and quality of life in Chinese patients with implantable cardioverter defibrillators✰

OBJECTIVES

Patient reported outcomes in Implantable Cardioverter Defibrillator (ICD) patients can describe the experience of living with heart disease and with an ICD. However, very little is known about patient outcomes among Chinese patients which may limit effective patient discussions and interventions for these patients. The purposes of this study were to examine device related experiences (e.g., device acceptance, shock anxiety) in Chinese ICD patients and identify potential variables that influence health related quality of life (HRQOL) and to compare HRQOL outcomes to healthy and heart failure populations.

METHODS

This study used a cross-sectional research design with serially recruited ICD patients (N = 100) from clinics in China. Participants completed surveys including: the 12-Item Short-Form Health Survey Questionnaire (SF-12), Florida Patient Acceptance Survey (FPAS), Florida Shock Anxiety Scale (FSAS), Type D Scale (DS-14), and general information questionnaire.

RESULTS

Participants were 100 ICD patients in China with a mean age of 53.32(SD = 13.70). The mean scores of the SF-12 physical component summary (PCS) and mental component summary (MCS)of ICD patients (43.55 and 47.07, respectively) were lower than the Chinese general population (P<0.001) and general health, social functioning, and role emotional scores were lower than chronic heart failure patients (P<0.001). Multiple linear regression analysis indicated that LVEF, positive shock history, age and shock anxiety were significant predictors of physical function and accounted for 24.5% of the adjusted variance. Type D personality, shock history, and shock anxiety were predictors of the mental health component and accounted for 25.9% of the variance. Shock history, age, type D personality, and shock anxiety significantly predicted device acceptance (FPAS-Total) and accounted for 32% of variance.

CONCLUSIONS

ICD patients reported health outcomes were generally lower than the Chinese general population and patients with heart failure in relation to general health, social functioning, and role emotional. Both generic and disease specific HRQOL were influenced by both medical and psychosocial predictors. This suggests that current Western society based comprehensive models of patient HRQOL and patient care needs may extend to Chinese patients with ICDs.

Quality of life and psychological co-morbidities in children and adolescents with cardiac pacemakers and implanted defibrillators: a cohort study in Eastern Germany

INTRODUCTION

The implantation of a pacemaker or an implantable cardioverter-defibrillator during childhood may reduce quality of life and lead to mental health problems. This study aimed to evaluate potential mental health problems (i.e., depressive and anxiety symptoms) and quality of life in children with cardiac active devices in comparison to healthy peers.

METHODS

We analysed data of children with pacemakers or implantable cardioverter-defibrillators aged 6-18 years. Quality of life, depressive and anxiety symptoms were assessed by standardised questionnaires. The results were compared to age-matched reference groups.

RESULTS

Children with implantable cardioverter-defibrillator showed significant lower quality of life in comparison to reference group (p = 0.03), but there was no difference in quality of life between children with pacemaker and reference group. There was no significant difference in depressive symptoms between children with a cardiac rhythm device compared to reference group (self-report: p = 0.67; proxy report: p = 0.49). There was no significant difference in anxiety (p = 0.53) and depressive symptoms (p = 0.86) between children with pacemaker and children with implantable cardioverter-defibrillator.

CONCLUSIONS

Living with an implantable cardioverter-defibrillator in childhood seems to decrease the patients' quality of life. Although children with pacemaker and implantable cardioverter-defibrillator don't seem to show more depressive and anxiety symptoms in comparison to their healthy peers, there still can be an increased risk for those children to develop mental health problems. Therefore, treating physicians should be aware of potential mental health problems and provide the patients and their families with appropriate therapeutic offers.

Multisymptom Profile Predicts Increased Risk of Poor Outcomes After Initial Placement of Implantable Cardioverter Defibrillator

CONTEXT

Patients with implantable cardioverter defibrillators (ICDs) are at risk for multiple physical and psychological symptoms. Identification of specific symptom profiles associated with poor outcomes may elucidate novel strategies to enhance symptom management.

OBJECTIVES

The objectives were to determine common symptoms after initial ICD implantation, identify classes of individuals with similar symptom profiles, describe patient characteristics associated with different symptom profiles, and determine if symptom profiles at hospital discharge predicted outcomes three and 12 months after implantation.

METHODS

This was a secondary data analysis of a randomized controlled trial that compared patient + partner versus patient-only interventions designed to help patients manage symptoms, prepare for ICD shocks, and resume daily activities. Symptoms were measured with the Patient Concerns Assessment. Latent class regression analysis was used to identify symptom classes at baseline, three-month, and 12-month follow-up. Associations between patient characteristics, class membership, and outcomes were examined using chi-square, analysis of variance, and Poisson regression.

RESULTS

The study included 301 patients (74% male, mean age 64 ± 11.9 years). Three classes were identified: Multi-Symptom (N = 119, 40%), Tired-Rundown (N = 130, 43%), and Mostly Asymptomatic (N = 52, 17%). Patients in the Multi-Symptom class were younger (59.9 years, P < 0.001) and reported more anxiety (P < 0.001) and depression (P < 0.01) than the other classes. Membership in the Multi-Symptom class predicted lower quality of life and resulted in nearly double the rate of hospitalizations after 12 months (P = 0.02, IRR 1.9).

CONCLUSION

Evaluation of symptom profiles after ICD implantation offers a promising strategy for identifying patients at risk for poor health outcomes.

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.

Optimal Strategies to Reduce Inappropriate Implantable Cardioverter-defibrillator Shocks

Since the widespread implementation of implantable cardioverter-defibrillators (ICDs), their effectiveness in various situations has become well-established. However, despite many advances in both the technology and its utilization, inappropriate therapy remains a risk. Here, we review ICD shocks, their effect on outcomes, and current methods to reduce inappropriate therapy, finding overall that inappropriate ICD shocks are common and associated with adverse outcomes. However, strategies do exist to minimize inappropriate shock rates including device selection and programming, medication, catheter ablation, and remote monitoring. Overall, ICDs are useful in reducing the risk of sudden cardiac death, but many patients with an ICD will receive an inappropriate shock. Understanding strategies to prevent inappropriate shocks is crucial to improving the care of patients with ICDs.

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.

Cardiac Resynchronization Therapy in Older Adults with Heart Failure

Heart failure is a disease of poor prognosis marked by frequent hospitalizations, premature death, and impaired quality of life. Despite advances in medical therapy for patients with heart failure and reduced ejection fraction, mortality and hospitalizations with advanced disease are still increased and the quality of life continues to be poor in this population. The advent of cardiac resynchronization therapy has led to a significant improvement in both survival and symptom management in patients with heart failure and reduced ejection fraction. Its beneficial effects in the elderly population, however, are not well-defined.

Influence of myopotential interference on the Wavelet discrimination algorithm in implantable cardioverter-defibrillator

Background

Wavelet is a morphology-based algorithm for detecting ventricular tachycardia. The electrogram (EGM) source of the Wavelet algorithm is nominally programmed with the Can-RV coil configuration, which records a far-field ventricular potential. Therefore, it may be influenced by myopotential interference.

Methods

We performed a retrospective review of 40 outpatients who had an implantable cardioverter-defibrillator (ICD) with the Wavelet algorithm. The percent-match score of the Wavelet algorithm was measured during the isometric chest press by pressing the palms together. We classified patients with percent-match scores below 70% due to myopotential interference as positive morphology change, and those with 70% or more as negative morphology change. Stored episodes of tachycardia were evaluated during the follow-up.

Results

The number of patients in the positive morphology change group was 22 (55%). Amplitude of the Can-RV coil EGM was lower in the positive morphology change group compared to that in the negative group (3.9±1.3 mV vs. 7.4±1.6 mV, P=0.0015). The cut-off value of the Can-RV coil EGM was 5 mV (area under curve, 0.89). Inappropriate detections caused by myopotential interference occurred in two patients (5%) during a mean follow-up period of 49 months, and one of them received an inappropriate ICD shock. These patients had exhibited positive morphology change.

Conclusions

The Wavelet algorithm is influenced by myopotential interference when the Can-RV coil EGM is less than 5 mV.

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.

Cardiac Pacing and Defibrillation Devices: Cost and Effectiveness

Implantable cardiac pacing and defibrillation devices are effective and commonly used therapies for patients with cardiac rhythm disorders. Because device implantation is not easily reversible, as well as the high healthcare costs inherent in device use, a clear understanding of the clinical benefits relative to costs is essential for both appropriate clinical use and rational policy making. Cardiac implantable electronic devices (CIEDs) have been among the best-investigated therapies in medicine; these devices have been the topic of numerous clinical and economic evaluations during the past 30 years. However, many important questions remain unclarified. We review the evidence supporting the clinical benefits of CIEDs, including effectiveness in extending survival as well as improving quality of life. We also summarize the economic studies that have investigated costs associated with these devices and their overall cost effectiveness, and we highlight important potential areas for future research.

Trajectories of patient-reported health status in patients with an implantable cardioverter defibrillator

To date, no study has assessed the course of patient-reported health status in patients with an implantable cardioverter defibrillator (ICD). Studying health status trajectories and their baseline determinants would permit the identification of patients at risk for poor health outcomes after ICD implantation. A combined cohort of 1,222 patients with an ICD (79% men; age = 61.4 [11.2] years) completed the 12-Item Short-Form Health Survey at baseline and 2 to 3 months and 12 to 14 months after implantation. Latent class analyses were used to identify trajectories and predictors of health status over time. Most health status trajectories showed a stable pattern after short-term follow-up, with differences between trajectories being mainly related to differences in absolute levels of health status. Seven trajectories were identified for physical health status. Being unemployed, symptomatic heart failure, ICD shock, psychotropic medication, negative affectivity, and type D personality were identified as independent determinants of poorer physical health status. For mental health status, 6 trajectories were identified. Younger age, low educational level, symptomatic heart failure, renal failure, no use of ACE inhibitors, psychotropic medication, negative affectivity, and type D personality were identified as independent determinants of poorer mental health status. In conclusion, the population with an ICD seems to be heterogeneous in terms of patient-reported physical and mental health status. Patients with an ICD who present with poor health status and a distressed personality profile should be timely identified and monitored as they may benefit from cardiac rehabilitation in combination with behavioral intervention.

Sex Is Associated With Differences in Individual Trajectories of Change in Social Health After Implantable Cardioverter-Defibrillator

Background—

Social health is a dimension of quality of life, and refers to people’s involvement in, and satisfaction with social roles, responsibilities, and activities. The implantable cardioverter-defibrillator is associated with changes in overall quality of life, but little is known about sex differences in individual trajectories of change in social health.

Methods and Results—

We prospectively measured changes in 3 subscales of the SF-36v2 generic health questionnaire (role physical, role emotional, and social functioning), 2 Patient-Reported Outcomes Measurement Information System short forms (satisfaction with participation in social roles and satisfaction with participation in discretionary social activities), and the Florida Patient Acceptance Survey before and at 1, 2, and 6 months after implantation. Individual growth models of temporal change were estimated. The scores of the 6 indicators improved with time. The unconditional model demonstrated significant (fixed effects: P <0.05; covariance parameters: P <0.10) residual variability in the individual trajectories. In the conditional model, men and women differed significantly in their rates of change in the scores of 3 of the 6 measures. Although men’s mean scores exceeded women’s mean scores on all indicators at baseline (range of relative mean difference: 11.0% to 17.8%), the rate of women’s change resulted in a reversal in relative standing at 6 months after implantation, with the mean scores of women exceeding the men’s by 4.5% to 5.6%.

Conclusions—

Men and women differed in their trajectories of change in social health, both in terms of their starting points (ie, baseline scores) and their rates of change.

Psychological effects of implantable cardioverter defibrillator shocks. A review of study methods

Background: The implantable cardioverter defibrillator (ICD) saves lives but clinical experience suggests that it may have detrimental effects on mental health. The ICD shock has been largely blamed as the main offender but empirical evidence is not consistent, perhaps because of methodological differences across studies.

Objective: To appraise methodologies of studies that assessed the psychological effects of ICD shock and explore associations between methods and results.

Data Sources: A comprehensive search of English articles that were published between 1980 and 30 June 2013 was applied to the following electronic databases: PubMed, EMBASE, NHS HTA database, PsycINFO, Sciencedirect and CINAHL.

Review Methods: Only studies testing the effects of ICD shock on psychological and quality of life outcomes were included. Data were extracted according to a PICOS pre-defined sheet including methods and study quality indicators.

Results: Fifty-four observational studies and six randomized controlled trials met the inclusion criteria. Multiple differences in methods that were used to test the psychological effects of ICD shock were found across them. No significant association with results was observed.

Conclusions: Methodological heterogeneity of study methods is too wide and limits any quantitative attempt to account for the mixed findings. Well-built and standardized research is urgently needed.

The impact of technology dependency on device acceptance and quality of life in persons with implantable cardioverter defibrillators

BACKGROUND

The impact of implantable cardioverter defibrillator (ICD) technology on the quality of life (QOL) experienced by recipients has been a major focus of recent research. Numerous studies have found psychological distress to be important in determining QOL in persons receiving ICDs, yet the source of psychological distress is not well understood.

OBJECTIVE

The aim of this study was to determine the impact of technology dependency on psychological outcomes in ICD recipients.

METHODS

With the use of a cross-sectional design, 161 ICD recipients from 1 device clinic were mailed self-administered questionnaires, including the Dependency on Technology Scale, Brief Illness Perception Questionnaire, Florida Shock Anxiety Scale, Florida Patient Acceptance Survey, and Short Form-12 (SF-12). Hierarchical multiple regressions and analyses of variance were performed.

RESULTS

The final sample size was 101 participants. Mean (SD) age was 68 (13) years; 72% of the participants were men, 99% were white, and 30% reported receiving a shock(s). A total of 80% reported positive attitudes toward technology dependency; 14%, neutral; and 6%, negative (Dependency on Technology Scale). Illness perceptions were positive (Brief Illness Perception Questionnaire; mean[SD], 34.5 [12.6]), shock anxiety was elevated (Florida Shock Anxiety Scale; mean [SD], 16.5 [6.7]), and device acceptance was good (Florida Patient Acceptance Survey; mean [SD], 74.9 [17.0]). Physical health QOL was low (SF-12; mean [SD], 38.6 [11.3]) and mental health QOL was moderate (SF-12; mean [SD], 50.6 [10.0]). Attitudes toward technology dependency significantly accounted for the variance seen in device acceptance and mental health QOL beyond age, gender, number of shocks, illness perceptions, and shock anxiety by 5.7% (P = .001) and 3.3% (P = .04), respectively. Significant differences were seen in device acceptance between those with negative and neutral attitudes (P = .001) and those with negative and positive attitudes (P < .001) and in shock anxiety and mental health QOL between those with negative and those with positive attitudes (P < .001).

CONCLUSIONS

Attitudes toward technology dependency is significantly associated with psychological outcomes and may explain the psychological distress in some ICD recipients. Degree of positivity toward technology dependency influences these outcomes. Research evaluating attitudes toward technology dependency and testing of interventions focusing on these attitudes is warranted.

Association of psychiatric history and type D personality with symptoms of anxiety, depression, and health status prior to ICD implantation

BACKGROUND

Personality factors and psychiatric history may help explain individual differences in risk of psychological morbidity and poor health outcomes in patients with an implantable cardioverter defibrillator (ICD).

PURPOSE

We examined associations between previous anxiety and depressive disorder, type D personality, anxiety or depressive symptoms, and health status in ICD patients prior to ICD implantation.

METHOD

Patients (N = 278; 83 % men; mean age = 62.2 years ±11) receiving a first ICD from September 2007 through April 2010 at the Medisch Spectrum Twente, The Netherlands completed validated questionnaires before implantation assessing type D personality (14-item Type D Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), and health status (36-item Short Form Health Survey). History of anxiety or depressive disorder was assessed with the Mini International Neuropsychiatric Interview structural interview.

RESULTS

Previous anxiety or depressive disorder was prevalent in 8 and 19 % of patients, respectively. Type D personality was present in 21 %, depressive symptoms in 15 %, and anxiety in 24 %. In adjusted analyses, type D personality was a dominant correlate of previous depressive disorder (odds ratio (OR) 6.2, p < 0.001) and previous anxiety disorder (OR 3.9, p = 0.004). Type D personality (OR 4.0, p < 0.001), age (OR 1.03, p = 0.043), and gender (OR 2.5, p = 0.013) were associated with anxiety symptoms at baseline. Type D personality (OR 5.9. p < 0.001) was also associated with increased depressive symptoms at baseline. Heart failure and type D personality were related to poorer health status.

CONCLUSION

In ICD patients, prior to ICD implantation, a previous anxiety or depressive disorder, type D personality, and anxiety and depressive symptoms were associated with poorer health status. Type D personality was also independently associated with increased anxiety and depression symptoms.

Living with an implantable cardiac defibrillator: a model of chronic uncertainty

Over the last two decades, the number of patients receiving implantable cardiac defibrillators (ICDs) for the prevention of sudden cardiac death has grown significantly. This growth is largely the result of broadened indication for ICD use because of the success of trials demonstrating efficacy. Early ICD indication centered on secondary prevention, which then advanced to primary prevention in high-risk patients. Nurses delivering care to these patients not only manage this complex technology but also patients' uncertainty about their survival and related psychosocial adjustment to receiving an ICD. To inform practice, theoretical models such as Mishel's (1988) uncertainty in illness model provide insight into such acute phases of illness. This article proposes expansion of the uncertainty in illness model to advance knowledge in this field for nurses caring for patients with ICD.

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.

Development and feasibility testing of decision support for patients who are candidates for a prophylactic implantable defibrillator: a study protocol for a pilot randomized controlled trial

BACKGROUND

Patients, identified to be at risk for but who have never experienced a potentially lethal cardiac arrhythmia, have the option of receiving an implantable cardioverter defibrillator (ICD) as prophylaxis against sudden cardiac death - a primary prevention indication. In Canada, there is no clear framework to support patients' decision-making for these devices. Decision support, using a decision aid, could moderate treatment-related uncertainty and prepare patients to make well-informed decisions. Patient decision aids provide information on treatment options, risks, and benefits, to help patients clarify their values for outcomes of treatment options. The objectives of this research are: 1) develop a decision aid, 2) evaluate the decision aid, and 3) determine the feasibility of conducting a trial.

METHODS/DESIGN

A development panel comprised of the core investigative team, health service researchers, decision science experts, cardiovascular healthcare practitioners, and ICD patient representatives will collaborate to provide input on the content and format of the aid. To generate probabilities to include in the aid, we will synthesize primary prevention ICD evidence. To obtain anonymous input about the facts and content, we will employ a modified Delphi process. To evaluate the draft decision aid will invite ICD patients and their families (n = 30) to rate its acceptability. After we evaluate the aid, to determine the feasibility, we will conduct a feasibility pilot randomized controlled trial (RCT) in new ICD candidates (n = 80). Participants will be randomized to receive a decision aid prior to specialist consultation versus usual care. Results from the pilot RCT will determine the feasibility of research processes; inform sample size calculation, measure decision quality (knowledge, values, decision conflict) and the influence of health related quality of life on decision-making.

DISCUSSION

Our study seeks to develop a decision aid, for patients offered their first ICD for prophylaxis against sudden cardiac death. This paper outlines the background and methods of a pilot randomized trial which will inform a larger multicenter trial. Ultimately, decision support prior to specialist consultation could enhance the decision-making process between patients, physicians, and families, associated with life-prolonging medical devices like the ICD.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01876173.

Dynamic analysis of cardiac rhythms for discriminating atrial fibrillation from lethal ventricular arrhythmias

BACKGROUND

Implantable cardioverter-defibrillators (ICDs), the first line of therapy for preventing sudden cardiac death in high-risk patients, deliver appropriate shocks for termination of ventricular tachycardia (VT)/ventricular fibrillation. A common shortcoming of ICDs is imperfect rhythm discrimination, resulting in the delivery of inappropriate shocks for atrial fibrillation (AF). An underexplored area for rhythm discrimination is the difference in dynamic properties between AF and VT/ventricular fibrillation. We hypothesized that the higher entropy of rapid cardiac rhythms preceding ICD shocks distinguishes AF from VT/ventricular fibrillation.

METHODS AND RESULTS

In a multicenter, prospective, observational study of patients with primary prevention ICDs, 119 patients received shocks from ICDs with stored, retrievable intracardiac electrograms. Blinded adjudication revealed shocks were delivered for VT/ventricular fibrillation (62%), AF (23%), and supraventricular tachycardia (15%). Entropy estimation of only 9 ventricular intervals before ICD shocks accurately distinguished AF (receiver operating characteristic curve area, 0.98; 95% confidence intervals, 0.93-1.0) and outperformed contemporary ICD rhythm discrimination algorithms.

CONCLUSIONS

This new strategy for AF discrimination based on entropy estimation expands on simpler concepts of variability, performs well at fast heart rates, and has potential for broad clinical application.

[Internet therapy for ICD-patients]

Implantable cardioverter-defibrillators (ICD) are increasingly used for the prevention of potentially lethal cardiac arrhythmias due to their confirmed superior medical efficiency. Nevertheless, ICD-patients often suffer from psychosocial problems, e.g., anxiety and depression. These issues are rarely addressed in routine medical follow-up care. Due to the limited mobility of many ICD-patients, Internet-based care may be ideal for delivering psychosocial care to patients in their homes. Our pilot study and case studies illustrate prospects and challenges of this approach. We developed icd-forum.de, a 6-week internet-based prevention program that provides a platform for information, a virtual self-help group, and a professionally moderated chat room in order to help decrease anxiety and to improve quality of life. A critical evaluation in the context of other published studies on the subject allows recommendations for the implementation of future internet-based psychosocial programs for ICD-patients to be deduced. It is the authors' opinion that such programs offer advantages specifically for heart failure patients and they recommend their broader use. Prior to this, conclusive evaluation studies are needed.

Comparison of male and female psychological outcomes related to implantable cardioverter defibrillators (COMFORTID)

BACKGROUND

While randomised, controlled trials have established the efficacy of the implantable cardioverter defibrillator (ICD) for primary and secondary prevention of life threatening arrhythmias, psychosocial responses remain complex and poorly understood, especially across Europe. There appears to be a greater need to understand differences in the experience of men and women.

AIM

The aim of this prospective study was to explore differences in psychosocial adjustment over a 12 month period following ICD implantation.

METHODS

Fourteen female and thirty three male device recipients completed a series of questionnaires over a 12 month period. Instruments included a generic and an ICD specific Quality of Life (QOL) measure and the state-trait anxiety inventory.

RESULTS

Women reported higher levels of anxiety than men at discharge but over time demonstrated a significant improvement such that at 4, 8 and 12 months men were more anxious. Women reported significantly poorer emotional wellbeing at discharge, however by 12 months this was significantly improved with no difference in the perceptions held by men and women. Women consistently across the 12 months worried more than men about the impact of the device on appearance.

CONCLUSION

This study confirmed that most individuals adjust positively to the ICD during the first 12 months. Some gender differences in adjustment were evident. Further studies across Europe are warranted to establish gender specific interventions to support men and women as they adapt to life with ICD implants.

COPE-ICD: patient experience of participation in an ICD specific rehabilitation programme

PURPOSE

Evaluating rehabilitation programmes from the patient's perspective is much needed, as the patients are the most important stakeholders in the health care system. A comprehensive rehabilitation programme, COPE-ICD programme, consists of exercise training and nursing consultations during a one year period post ICD implantation. The purpose of this paper is to describe the experience and meaning of participating in a comprehensive ICD-specific rehabilitation programme.

METHODS

Qualitative interviews were conducted with 10 patients representing the participating population, and later transcribed. The analysis was inspired by Ricoeur's theory of interpretation, which consists of three levels: naive reading, structured analysis and critical interpretation and discussion.

RESULTS

The overall concept was that participating in the COPE-ICD programme meant feeling inspired and secure through individualized care. Four themes emerged: Knowledge: patients gained much needed understanding; Physical attention: patients interpreted body signals and adjusted their exercise behaviour; Trust: patients regained trust, felt secure and dared to live again; Strategies of living: patients' coping was supported through reflection and professional dialogue, and they dealt with the risk of shock or death.

CONCLUSION

Participating in an ICD-specific rehabilitation programme can make patients feel inspired and secure through individualized care. They discover that they have to rethink some of their strategies of living and they gain support in the reflection and coping needed for that. Patients gain insight and they develop a special physical attention whereby they continue healthy activities through interpreting body signals and adjusting exercise behaviour. They learn to trust their body again.

The prevalence of anxiety and depression in adults with implantable cardioverter defibrillators: a systematic review

OBJECTIVE

The implantable cardioverter defibrillator (ICD) is used to treat life-threatening ventricular arrhythmias and in the prevention of sudden cardiac death. A significant proportion of ICD patients experience psychological symptoms including anxiety, depression or both, which in turn can impact adjustment to the device. The objective of this systematic review was to assess the prevalence of anxiety and depression or symptoms of anxiety and depression among adults with ICDs.

METHODS

Search of MEDLINE®, CINAHL®, PsycINFO®, EMBASE® and Cochrane® for English-language articles published through 2009 that used validated diagnostic interviews to diagnose anxiety or depression or self-report questionnaires to assess symptoms of anxiety or depression in adults with an ICD.

RESULTS

Forty-five studies that assessed over 5000 patients were included. Between 11% and 28% of patients had a depressive disorder and 11-26% had an anxiety disorder in 3 small studies (Ns=35-90) that used validated diagnostic interviews. Rates of elevated symptoms of anxiety (8-63%) and depression (5-41%) based on self-report questionnaires ranged widely across studies and times of assessment. Evidence was inconsistent on rates pre- versus post-implantation, rates over time, rates for primary versus secondary prevention, and for shocked versus non-shocked patients.

CONCLUSION

Larger studies utilizing structured interviews are needed to determine the prevalence of anxiety and depression among ICD patients and factors that may influence rates of anxiety and depressive disorders. Based on existing data, it may be appropriate to assume a 20% prevalence rate for both depressive and anxiety disorders post-ICD implant, a rate similar to that in other cardiac populations.

The distressed (Type D) personality. A risk marker for poor health outcomes in ICD patients

The distressed (Type D) personality is an emerging risk marker for poor health outcomes in patients with cardiovascular disease. Patients with this personality disposition are typified by a general propensity to experience psychological distress. The contribution focuses on the impact of Type D personality on psychological distress, quality of life, ventricular tachyarrhythmias, and mortality in implantable cardioverter-defibrillator (ICD) patients and examines the relative influence of this vulnerability factor compared to ICD shocks and markers of disease severity in relation to these outcomes.

Depression and coping as predictors of change after deep brain stimulation in Parkinson's disease

BACKGROUND

This study examined changes in motor function and quality of life (QoL) after subthalamic nuclei deep brain stimulation (STN-DBS) in patients with Parkinson disease (PD) and the role of psychosocial predictors on individual changes.

METHODS

Forty-one patients with advanced PD (29 men and 12 women; mean age: 62.0 ± 8.0; disease duration: 14.5 ± 5.7) completed self-report questionnaires before surgery and at 6 and 12 months after surgery. Psychosocial measures assessed coping strategies (Ways of Coping Checklist-Revised), symptoms of depression (Beck Depression Inventory version II), anxiety (State-Trait Anxiety Inventory), and QoL (Parkinson Disease Questionnaire 39 Items, Medical Outcomes Study 36-Item Short-Form Health Survey).

RESULTS

After surgery, motor function (Unified Parkinson Disease Rating Scale III and IV), global QoL (Parkinson Disease Questionnaire 39 Items) and Physical Component Summary of the Medical Outcome Study Short Form 36-items Health Survey improved, whereas the Mental Component Summary tended to deteriorate. Depression and anxiety were stable. Improvements in motor function and QoL were associated with younger age, shorter duration of illness, higher baseline distress (depression and anxiety), and changes in problem-focused coping. Improvements in mental QoL were associated with a less frequent use of coping focused on seeking social support.

CONCLUSIONS

STN-DBS is associated with major positive changes in PD affecting motor function and QoL. These changes are related to psychological variables, including emotional distress and coping. A better focus on these individual characteristics is necessary to improve care of patients with PD who undertake STN-DBS.

COPE-ICD: a randomised clinical trial studying the effects and meaning of a comprehensive rehabilitation programme for ICD recipients -design, intervention and population

Background

Growing evidence exists that living with an ICD can lead to fear and avoidance behaviour including the avoidance of physical activity. It has been suggested that psychological stress can increase the risk of shock and predict death. Small studies have indicated a beneficial effect arising from exercise training and psychological intervention, therefore a large-scale rehabilitation programme was set up.

Methods/Design

A mixed methods embedded experimental design was chosen to include both quantitative and qualitative measures. A randomised clinical trial is its primary component. 196 patients (power-calculated) were block randomised to either a control group or intervention group at a single centre. The intervention consists of a 1-year psycho-educational component provided by two nurses and a 12-week exercise training component provided by two physiotherapists. Our hypothesis is that the COPE-ICD programme will reduce avoidance behaviour, sexual dysfunction and increase quality of life, increase physical capability, reduce the number of treatment-demanding arrhythmias, reduce mortality and acute re-hospitalisation, reduce sickness leading to absence from work and be cost-effective. A blinded investigator will perform all physical tests and data collection.

Discussion

Most participants are men (79%) with a mean age of 58 (range 20-85). Most ICD implantations are on primary prophylactic indication (66%). 44% is NYHA II. Mean walk capacity (6MWT) is 417 m. Mean perception of General Health (SF-36) is PCS 42.6 and MCS 47.1.

A large-scale ICD rehabilitation trial including psycho-educational intervention and exercise training has been initiated and will report findings starting in 2011.

Trial Registration

ClinicalTrials.gov: NCT00569478

Gender disparities in psychological distress and quality of life among patients with an implantable cardioverter defibrillator

A subset of patients with an implantable cardioverter defibrillator (ICD) reports psychological distress and poor quality of life (QoL). Gender is one of the factors that has been proposed to explain individual differences in these outcomes. In this viewpoint, we (1) review the evidence for gender disparities in psychological distress and QoL in ICD patients by means of a systematic review, and (2) provide recommendations for future research and clinical implications. A systematic search of the literature identified 18 studies with a sample size ≥ 100 that examined gender disparities in anxiety/depression and QoL in ICD patients (mean prevalence of women = 21%; mean age = 62 years). Our review shows that there is insufficient evidence to conclude that gender per se is a major autonomous predictor for disparities in psychological distress and QoL in ICD patients. Women had a higher prevalence of anxiety and poorer QoL in some studies, but there was no statistically significant gender effect in relation to 80% (26/32) of the outcomes reported in the 18 studies. Studies are warranted that are designed a priori and sufficiently powered to examine gender disparities in distress and QoL outcomes in order to establish the exact gender-specific effect. Due to a need to explore the complexity of this issue further, at this time, caution is warranted with respect to the clinical implications.

Optimal Programming of ICDs for Prevention of Appropriate and Inappropriate Shocks

Expansion of indications for implantable cardioverter-defibrillators (ICDs) has led to a significant increase in the number of patients receiving ICDs and the number of lives saved because of ICD therapy. However, appropriate or inappropriate shocks are frequent and may result in a significant decrease in quality of life in patients with ICDs. Atrial fibrillation with rapid ventricular response, sinus tachycardia, atrial tachycardia or atrial flutter with rapid conduction, and other supraventricular tachycardias are the most common arrhythmias causing inappropriate therapy. Other causes include oversensing of diaphragmatic potentials or myopotentials, T-wave oversensing, double or triple counting of intracardiac signals, lead fractures or header connection problems, lead chatter or noise, and electromagnetic interference. Strategies to reduce inappropriate therapy using device programming rely on the ability to distinguish supraventricular and atrial arrhythmias from ventricular tachycardia. Avoiding therapy for nonsustained ventricular arrhythmias and increasing the role of antitachycardia pacing to terminate ventricular tachycardia are key approaches to reducing shocks for ventricular arrhythmias. Optimal programming holds great promise for decreasing the overall incidence of shock therapy and increasing ICD acceptance.

Long-term follow-up study of uncertainty and psychosocial adjustment among implantable cardioverter defibrillator recipients

BACKGROUND

Sudden cardiac death is an international health issue. Implantable defibrillators have been effective in the secondary prevention of sudden cardiac death and are increasingly being utilized for primary prevention in individuals without a prior history of cardiac arrest or sustained ventricular tachycardia. Although it has been well documented that some recipients experience psychological distress and have difficulty in adjusting to the device, long-term data on psychological outcomes are limited.

OBJECTIVES

The aims of this study were to determine: (a) if there is a long-term relationship between uncertainty and psychosocial adjustment among implantable cardioverter defibrillator (ICD) recipients; and (b) if changes in uncertainty and/or adjustment occur over time.

DESIGN

A longitudinal, descriptive, correlational design was used for this long-term follow-up study (M=9.4 years, SD=.23).

SETTING AND PARTICIPANTS

Ninety-four patients from 4 major teaching hospitals in New England who had participated in an investigation of uncertainty and adjustment at 1 and 8 weeks following an initial ICD implant between 1996 and 1997 were solicited. From the original sample, 41 patients had expired (44%) and 5 had heart transplants (5%). Two individuals chose not to participate. Twenty-five persons (27%) were not found despite numerous attempts to locate them. The final sample included 21 subjects (22%).

METHODS

Following university institutional review board approval, a mail survey was administered using the Dillman method. Instruments included a demographic data questionnaire, the Psychosocial Adjustment to Illness Scale-Self-Report and the 2-factor version of the Mishel Uncertainty in Illness Scale.

RESULTS

The final sample primarily included educated, married, white males. Uncertainty and adjustment levels did not change significantly over time. Early adjustment explained 40% of the variance in overall adjustment at long-term follow-up (P=.010). Men experienced significantly more uncertainty overall [t(19)=2.925, P=.009] and complexity related to living with the device [t(19)=3.62, P=.002].

CONCLUSIONS

Patients should be screened for psychological distress prior to device implantation so early intervention can be provided. Qualitative research is recommended to determine whether gender specific needs related to living with an ICD exist. More quantitative, long-term longitudinal data are also needed.