Improving Communication in Heart Failure Patient Care

BACKGROUND

Although implantable cardioverter-defibrillators (ICDs) reduce sudden death, these patients die of heart failure (HF) or other diseases. To prevent shocks at the end of life, clinicians should discuss deactivating the defibrillation function.

OBJECTIVES

The purpose of this study was to determine if a clinician-centered teaching intervention and automatic reminders increased ICD deactivation discussions and increased device deactivation.

METHODS

In this 6-center, single-blinded, cluster-randomized, controlled trial, primary outcomes were proportion of patients: 1) having ICD deactivation discussions; and 2) having the shocking function deactivated. Secondary outcomes included goals of care conversations and advance directive completion.

RESULTS

A total of 525 subjects were included with advanced HF who had an ICD: 301 intervention and 224 control. At baseline, 52% (n = 272) were not candidates for advanced therapies (i.e., cardiac transplant or mechanical circulatory support). There were no differences in discussions (41 [14%] vs. 26 [12%]) or deactivation (33 [11%] vs. 26 [12%]). In pre-specified subgroup analyses of patients who were not candidates for advanced therapies, the intervention increased deactivation discussions (32 [25%] vs. 16 [11%]; odds ratio: 2.90; p = 0.003). Overall, 99 patients died; there were no differences in conversations or deactivations among decedents.

SECONDARY OUTCOMES

Among all participants, there was an increase in goals of care conversations (47% intervention vs. 38% control; odds ratio: 1.53; p = 0.04). There were no differences in completion of advance directives.

CONCLUSIONS

The intervention increased conversations about ICD deactivation and goals of care. HF clinicians were able to apply new communication techniques based on patients' severity of illness. (An Intervention to Improve Implantable Cardioverter-Defibrillator Deactivation Conversations [WISDOM]; NCT01459744).

Disease understanding in patients newly diagnosed with atrial fibrillation

OBJECTIVE

To describe self-reported disease understanding for newly diagnosed patients with atrial fibrillation (AF) and assess (1) how disease understanding changes over the first 6 months after diagnosis and (2) the relationship between patient understanding of therapies at baseline and treatment receipt at 6 months among treatment-naïve patients.

METHODS

We analysed survey data from SATELLITE (Survey of Patient Knowledge and Personal Priorities for Treatment), a substudy of patients with new-onset AF enrolled in the national Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) II registry across 56 US sites. Patients were surveyed at the baseline and 6-month follow-up clinic visits using Likert scales.

RESULTS

Among 1004 baseline survey responses, patients' confidence in their understanding of rhythm control, ablation, anticoagulation and cardioversion was suboptimal, with 'high' understanding ranging from 8.5% for left atrial appendage closure to 71.3% for rhythm therapy. Of medical history and demographic factors, education level was the strongest predictor of reporting 'high' disease understanding. Among the 786 patients with 6-month survey data, significant increases in the proportion reporting high understanding were observed (p<0.05) only for warfarin and direct oral anticoagulants (DOACs). With the exception of ablation, high understanding for a given therapeutic option was not associated with increased use of that therapy at 6 months.

CONCLUSIONS

About half of patients with new-onset AF understood the benefits of oral anticoagulant at the time of diagnosis and understanding improved over the first 6 months. However, understanding of AF treatment remains suboptimal at 6 months. Our results suggest a need for ongoing patient education.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov. Identifier: NCT01701817.

Electroconvulsive therapy on Hungarian websites

BACKGROUND

Although there are several similarities in terms of their equipment and the way they are performed, the social perception and public attitudes towards electroconvulsive therapy (ECT) and electric cardioversion (ECV) is entirely different. The aim of this study was to assess and compare the information on Hungarian Internet sites on ECT and ECV with respect to their depiction and acceptance by the public.

SUBJECTS AND METHODS

An Internet search was undertaken with the Google search engine using the terms "ECT", "electroconvulsive therapy", "electroshock", "defibrillator" and "electric cardioversion". The search was restricted to information published in the Hungarian language from 1 January 2000 to 31 December 2010. All communications were classified into negative, neutral and positive groups depending on their attitude towards the aforementioned treatment methods. Professional or non-professional categories were also distinguished.

RESULTS

The total number of communications, which appeared between 2000 and 2010 and contained one of the search words for ECT was 66. The majority of them portrayed ECT in a negative (24; 36.4%) or neutral (25; 37.9%) fashion. Most of the websites (139; 95.2%) related to ECV were reflected positive (120; 82.2%) and neutral opinions (19; 13.0%).

CONCLUSIONS

Hungarian-language Internet sites mainly view ECT as negative or neutral in contrast to ECV cardioversion, which has almost entirely a positive reputation. Although the effectiveness of both therapies is equally well established, their public image as manifested on the Internet differs significantly. This may have a major impact on the frequency of their use.

Psychological and social impacts of automated external defibrillators (AEDs) in the home

BACKGROUND

The majority of cardiac arrests occur in the home. The placement of AEDs in the homes of at-risk patients may save lives through early defibrillation. However, the impact of having an AED in the home on psychological outcomes and quality-of-life is unknown.

OBJECTIVE

The purpose of this research was to determine whether training in the use of and possessing an automated external defibrillator (AED) has an effect on a patient at risk's quality of life.

METHODS

We investigated the psychological consequences of AED training and possession of such a device for patients who recently experienced an acute ischemic event. One hundred fifty eight patients and their family members were assigned at random to receive cardiopulmonary resuscitation (CPR) training (N=66) or AED/CPR training and possession of the device after training (N=92). We measured quality of life using the Short-Form (SF-36) survey and a 9-item survey we developed specifically for this study to measure differences in social activities and worries about being left alone. Participants answered these questions at enrollment, 2 weeks, 3 months, and 3 months after enrollment.

RESULTS

Patients in the AED group reported lower (worse) scores on most SF-36 subscales at all periods, particularly in those subscales relating to social functioning. The differences were most often small and probably not clinically meaningful. The social activities/worry scales also favored the CPR group at all periods, but with no significant differences.

CONCLUSIONS

Physicians counselling patients about AEDs should be aware of the potential effects the device may have on a patient's social functioning.

Anxiety and marital adjustment in patients with implantable cardioverter defibrillator and their spouses

PURPOSE

Device-related fears are a pervasive psychosocial difficulty that patients with implantable cardioverter defibrillators (ICDs) experience. Spouses also encounter anxieties that may influence patient and spouse adjustment. This study examined anxiety and marital adjustment among ICD patients and spouses, as well as intersex differences between female and male patients.

METHODS

Patients and their spouses (N=62) completed separate individual assessment batteries regarding demographics, death anxiety, shock anxiety, general anxiety, and marital adjustment at a single time point during outpatient cardiology visits.

RESULTS

Analyses revealed similar general anxiety and marital adjustment among participants, although spouses reported greater shock anxiety than did patients (P = .045). Female ICD patients reported more anxiety related to death and shock and received more shocks, despite equivalent indices of medical severity (P = .002).

CONCLUSIONS

This study suggests that spouses of ICD patients experience higher levels of shock anxiety than do patients themselves and that female ICD patients experience higher levels of shock anxiety and death (anxiety than do male patients. Results suggest future research of device specific anxiety and clinical attention devoted to ICD patient spouses and female ICD patients.

Measurement of patient fears about implantable cardioverter defibrillator shock: an initial evaluation of the Florida Shock Anxiety Scale

BACKGROUND

Psychological distress is both a precipitant and a consequence of ICD shock. Therefore, the assessment of patient anxiety and concerns related to receiving an ICD shock may prompt appropriate psychological referrals and treatment.

METHODS

The purpose of this study is to assess the initial validity and clinical utility of the Florida Shock Anxiety Scale (FSAS). Seventy-two ICD recipients completed the FSAS.

RESULTS

Exploratory factor analysis revealed a two-factor structure with items loading such that Factor 1 could be conceptualized as a Consequence Factor (e.g., fearing creating a scene if the device were to fire) and Factor 2 as a Trigger Factor (e.g., fearing sexual activity). Alpha coefficients suggest good reliability (Cronbach's alpha= 0.91, split-half = 0.92), and FSAS Total Score was moderately correlated (r =-0.65) with total score on the Multidimensional Fear of Death Scale.

CONCLUSIONS

Two subscales, labeled consequence of shock and trigger of shock, were established via factor analysis. Collectively the FSAS demonstrates potential utility to assess shock distress and warrants additional investigation.

A change of heart. Interview by Carol Davis

One Cambridge nurse has transformed the service for people needing elective cardioversion. Instead of complaints, the hospital now receives plaudits and its success has garnered an award.

Quality of life in implanted cardioverter defibrillator recipients: the impact of a device shock

BACKGROUND

The success of the implanted cardioverter defibrillator (ICD) in prolonging the life of patients with arrhythmia suggests a need to assess quality of life (QOL), especially in those who receive an ICD shock.

OBJECTIVES

The purpose of this study was to compare QOL in a group who received an ICD shock with a group who did not receive an ICD shock during the first year.

METHODS

Fifty-nine subjects, 42 men and 17 women with a mean age 63 years, completed the Medical Outcomes Study Short Form-36, Ferrans and Powers QOL Index, Profile of Mood States at implantation and 1 year, and the Brodsky ICD Questionnaire at 1 year.

RESULTS

Thirty-seven percent received an ICD shock. Those in the shock group had worse mental health ( P < or = .04) and vitality scores ( P < or = .03) on the Short Form-36, increased anxiety ( P < or = .015), fatigue ( P < or = .005), and psychologic distress ( P < or = .02), as measured by Profile of Mood States, compared with the no shock group at 1 year.

CONCLUSIONS

Shocked ICD recipients demonstrate mental health concerns.

Concerns about the implantable cardioverter defibrillator: a determinant of anxiety and depressive symptoms independent of experienced shocks

BACKGROUND

Patients with an implantable cardioverter defibrillator (ICD) are at increased risk of anxiety disorders. In turn, anxiety has been identified as a precipitant of ventricular arrhythmias. Anxiety may in part be attributed to concerns about the ICD firing, but the relationship between ICD concerns, psychological morbidity, and shocks has not been systematically investigated. We examined the relative importance of experienced shocks versus subjective concerns about the ICD as determinants of anxiety and depressive symptoms in ICD patients.

METHODS

Consecutive surviving patients ( n = 182, response rate = 82%) having had an ICD implanted between October 1998 and January 2003 at the Erasmus Medical Centre Rotterdam were asked to fill in the ICD Patient Concerns Questionnaire and the Hospital Anxiety and Depression Scale. Clinical variables were obtained from the patients' medical records.

RESULTS

A total of 55 (30%) patients had received a shock from the ICD. Although patients who had experienced a shock scored higher on ICD concerns, ICD concerns was the only independent determinant of anxiety (odds ratio 6.35, 95% CI 2.84-14.20) and depressive symptoms (odds ratio 2.29, 95% CI 1.06-4.96) adjusting for shocks and all other factors.

CONCLUSIONS

Patient concerns about the ICD may be an important indicator of psychosocial adjustment. Screening for ICD patient concerns using the ICD Patient Concerns Questionnaire may identify patients at risk for psychological morbidity after ICD implantation.

Satisfaction With Treatment and Prevalence of Discomfort After External Electrical Cardioversion

The objective of this study was to evaluate patient satisfaction with direct current (DC) cardioversion and the prevalence of discomfort after the process. A descriptive study of patients (N = 75) who underwent DC cardioversion in the cardiology department of the Juan Canalejo Hospital, Spain, was conducted. As many as 53.8% of the patients stated that they experienced discomfort with DC cardioversion. The factors associated with relatively more discomfort were being a female and younger age. Receiving information before DC cardioversion protected against discomfort (OR = 0.16). All of the patients were satisfied with the way they were treated, but 21.2% were not satisfied with the results. After adjusting for different covariates, patients who were informed about cardioversion before the procedure were more satisfied with the treatment (OR = 4.9). The patients showed a high degree of satisfaction with the treatment received. Information increases the probability of satisfaction and decreases discomfort.

ICD: a qualitative study of patient experience the first year after implantation

BACKGROUND

The experiences of how patients live with an implantable cardioverter defibrillator are still poorly understood. Only a few qualitative studies have investigated this phenomenon. This paper was undertaken as part of a larger project to evaluate quality of life and psychological well-being in those survivors of cardiac arrest who have received an implantable cardioverter defibrillator.

AIMS AND OBJECTIVES

The aim of this qualitative study was to explore how implantable cardioverter defibrillator recipients perceive their lives during the first year after implantation of the device.

METHODS

A sample of 21 patients who received an implantable cardioverter defibrillator was interviewed during three consecutive periods: one, six and 12 months postdischarge from the hospital. The semi-structured interviews were based on insights gained from a literature review. The transcripts were subjected to content analysis.

RESULTS

Analysis of the data revealed seven major categories: physical deterioration, cognitive changes, perceived social support, dependency, contact with the doctor, confrontation with mortality and uncertainty surrounding having a shock. Anxiety, uncertainty, disappointment, frustration, unexpected barriers, acceptance of and dependency on the implantable cardioverter defibrillator played a major role in the lives of implantable cardioverter defibrillator recipients. Well-being improved throughout the year. During the first months after discharge from the hospital the focus was on regaining physical health. During the early postimplantation period both the implantable cardioverter defibrillator recipient and family members had adapted to the situation. Reflection on the impact and consequences of the cardiac arrest was reported more often in the late postimplantation period.

CONCLUSIONS

Content analysis is a resourceful approach giving answers to questions that have hardly been addressed within the domain of cardiology. Implantable cardioverter defibrillator recipients face a complex first year, especially the first 6 months. Cognitive deterioration and confrontation with mortality are problems that need to be researched further.

RELEVANCE TO CLINICAL PRACTICE

Caregivers are able to explain to future patients what they can expect in the first year after implantation. Caregivers may become more receptive to physical, psychological and social limitations and to emotional and social problems that occur in implantable cardioverter defibrillator recipients, enabling them to act upon them.

Psychosocial aspects of patient-activated atrial defibrillation

Atrial Defibrillator.

INTRODUCTION

The atrial defibrillator empowers patients to cardiovert themselves from atrial arrhythmias at a time that is socially and physically acceptable, thereby preventing hospitalization. The long-term psychosocial effects of repeated use of the patient-activated atrial defibrillator at home are unknown.

METHODS AND RESULTS

Eighteen patients underwent placement of the Jewel AF atrial defibrillator for persistent atrial fibrillation only. All patients performed manually activated cardioversions at home under self-administered sedation. Automatic shock therapies were disabled. Hospital Anxiety and Depression Scale and Multidimensional Health Locus of Control questionnaires were obtained before implant. All patients completed questionnaires 1 year after device implant and at long-term follow-up. The spouse or partner of each patient was interviewed to identify positive and negative aspects of manual cardioversion at home. The baseline patient scores for both anxiety (5.7 +/- 2.7) and depression (3.4 +/- 2.3) fell within the predefined range of normality. At 1 year, there was no significant change in anxiety (4.9 +/- 3.7, P = 0.39) or depression (2.4 +/- 1.8, P = 0.06). At long-term follow-up (mean 28 months), a total of 377 patient-activated cardioversions were performed out of hospital (median 15 per patient). Scores for anxiety (6.0 +/- 4.0, P = 0.70) and depression (3.2 +/- 2.5, P = 0.68) remained unchanged.

CONCLUSION

During long-term follow-up, patient-activated cardioversion using the atrial defibrillator was not associated with increased anxiety or depression. The procedure was well tolerated by patients and their partners, offering an acceptable treatment option for patients with recurrent persistent atrial fibrillation.

Absence of an impact of emotional distress on the perception of intracardiac shock discharges

The pain of transvenous cardioversion shocks in awake patients is an important clinical problem. It is unknown whether psychological factors modulate any observed variation in pain perception. Thirty-seven patients with chronic atrial fibrillation (AF; mean age 61.9 years, 29 men, 8 women) were consecutively included in the study. Pain perception of a low energy test shock (60V, 0.1J) during internal cardioversion was assessed immediately following the stimulus. Before treatment anxiety, depression, somatization were evaluated. The intracardiac shock was perceived as hypalgesic in 15 (41%) patients, as normalgesic in 10 (27%), and as hyperalgesic in 10 (32%) patients. Pain threshold was significantly lower in patients in which AF was accidentally diagnosed (p < 0.029). Age, sex, and the level of education were equally distributed over the three pain groups. The hyperalgesic pain threshold was not associated with anxiety, depression, or the patients' tendency to amplify benign bodily sensations. This study discloses a wide range of perceived pain intensity caused by a homogenous intracardiac stimulation. Anxiety and depression do not amplify perception of intracardiac shocks. Sensory gating mechanisms may play a more important role in the level of intracardiac shock perception than distressing affective factors.

Willingness of high school students to perform cardiopulmonary resuscitation and automated external defibrillation

OBJECTIVE

To evaluate the willingness of high school students to perform cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED).

METHODS

A convenience sample of high school students was surveyed regarding how they would respond if they witnessed a cardiac arrest. Participants were first shown a video segment on the operation of an automated external defibrillator. They were then shown a series of video clips depicting six different cardiac arrest scenarios: motor vehicle collision (MVC) with facial bleeding, pediatric drowning, intravenous (IV) drug user, choking family member, victim of differing race, and victim with facial vomitus. Following each video, the subjects were asked how they would respond had they actually witnessed a similar event.

RESULTS

With parental permission and institutional review board approval, 683 students participated, representing 6.8% of the total student body. Of these, 585 (86%) were trained in CPR and 142 (21%) in AED. One hundred six participants (16%) had witnessed a cardiac arrest prior to the survey. Of these, 24 (23%) had intervened in some way. Twenty (19%) had performed mouth-to-mouth resuscitation (MMR), 15 (14%) had performed chest compressions (CC), and one (0.9%) had performed AED. Across all six mock scenarios and all 683 respondents collectively (4,098 simulated cardiac arrest events), the respondents indicated they would be willing to perform AED 1,308 times (32%). In comparison, the respondents indicated they would be willing to perform MMR 1,768 times (43%) and CC 2,249 times (55%). More respondents were willing to intervene on behalf of a child or family member, while fewer were willing to act in the setting of blood, vomitus, or an IV drug user (p < 0.05). There was no association between willingness to intervene and prior experience with any of the interventions. Fear of infection, legal consequences, and fear of harming the patient were the most frequently cited reasons for not intervening.

CONCLUSIONS

Among high school students, few are willing to perform automated external defibrillation. Willingness to perform MMR and CC appears to depend on the circumstances.

Impact of in-home defibrillators on postmyocardial infarction patients and their significant others: an interview study

OBJECTIVE

To investigate the impact of automated external defibrillator (AED) placement in the homes of postmyocardial infarction (MI) patients and their significant others.

DESIGN

This qualitative study used a semistructured interview to examine a nonrandomized convenience sample recruited from a larger study of home AEDs.

SETTING AND PARTICIPANTS

Patients (and their significant others) were recruited from an ongoing study of AED use in the home. Seventeen interviews with 15 patients (14 men, 1 woman) and 16 significant others (1 man, 15 women) aged 39 to 80 years were performed in patients' homes.

METHODS

Verbatim transcripts of audiotaped interviews were reviewed, and responses were categorized. Other data were obtained from hospital chart abstraction.

RESULTS

The majority of subjects noted only positive effects of the presence of home AEDs (eg, giving them feelings of security and control). There was no evidence that AED presence in the home caused excessive anxiety or stress either in patients or their significant others, nor were they perceived to cause relationship stress. On average, patients and their significant others estimated a 38% and 43% (respectively) risk of cardiac arrest and a 92% and 87% likelihood of a successful resuscitation with the use of the AED. Subjects' perceived risk of cardiac arrest were subjectively related to their estimate of current health status, size of infarction, and symptoms during their MI. Subjects also related their estimates of risk to their likelihood of traveling with their AED and whether they would consider purchasing one. Significant others had high confidence in their ability to properly use the AED.

CONCLUSIONS

AEDs were valued highly by subjects and enhanced their perceived control over their heart disease. This was especially true for subjects who believed that their risk of cardiac arrest was high. The possible effects of providing education regarding expert estimates of the likelihood of cardiac arrest and of a successful resuscitation at the time of AED placement are discussed.

Intentions to use an automated external defibrillator during a cardiac emergency among a group of seniors trained in its operation

OBJECTIVE

By decreasing the time to defibrillation, automated external defibrillators (AEDs) provide an opportunity for lay people to improve survival in out-of-hospital sudden cardiac arrest. We examined how beliefs, expectations, and actual performance are related to intentions to use an AED during a future heart emergency among a group of seniors.

DESIGN AND OUTCOME MEASURES

One hundred fifty-nine seniors who had been previously trained in the operation of an AED were tested on their AED skills and asked about their perceptions regarding their AED skills; their expectations that an AED would save the life of a cardiac arrest victim; and their intentions to use an AED during a future cardiac event.

RESULTS

Logistic regression analyses showed that greater self-perceived ability to use an AED better actual performance on skills assessment but not expectations regarding the efficacy of AED treatment were independently associated with positive intentions to use an AED in a future heart emergency.

CONCLUSIONS

The likelihood that an elderly lay bystander will actually use an AED during a cardiac event may be closely tied to perceptions of his or her ability to operate an AED.

Dispatcher assistance and automated external defibrillator performance among elders

OBJECTIVES

Automated external defibrillators (AEDs) provide an opportunity to improve survival in out-of-hospital, ventricular fibrillation (VF) cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. The potential role of emergency dispatchers in the layperson use of AEDs is uncertain. This study was performed to examine whether dispatcher telephone assistance affected AED skill performance during a simulated VF cardiac arrest among a cohort of older adults. The hypothesis was that dispatcher assistance would increase the proportion who were able to correctly deliver a shock, but might require additional time.

METHODS

One hundred fifty community-dwelling persons aged 58-84 years were recruited from eight senior centers in King County, Washington. All participants had received AED training approximately six months previously. For this study, the participants were randomized to AED operation with or without dispatcher assistance during a simulated VF cardiac arrest. The proportions who successfully delivered a shock and the time intervals from collapse to shock were compared between the two groups.

RESULTS

The participants who received dispatcher assistance were more likely to correctly deliver a shock with the AED during the simulated VF cardiac arrest (91% vs 68%, p = 0.001). Among those who were able to deliver a shock, the participants who received dispatcher assistance required a longer time interval from collapse to shock [median (25th, 75th percentile) = 193 seconds (165, 225) for dispatcher assistance, and 148 seconds (138, 166) for no dispatcher assistance, p = 0.001].

CONCLUSIONS

Among older laypersons previously trained in AED operation, dispatcher assistance may increase the proportion who can successfully deliver a shock during a VF cardiac arrest.

[Electroconvulsive therapy and defibrillation in the paper. An analysis of the media]

In our study on Psychiatry, Mass Media and Public Opinion we made a content analysis of newspaper reports on ECT and electric defibrillation. We traced only few special articles on the subject in the 1994 and 1995 CD-Rom versions of the "Der Spiegel", The "Frankfurter Allgemeine Zeitung" (FAZ), the "Neue Zürcher Zeitung" (NZZ) and the "Berliner Tageszeitung" (taz), although the word "Elektroschock" was employed 118 times. Even in high standard newspapers the style of language becomes special when they deal with ECT. The articles are strongly biased and lack informations. In contrast to Defibrillation ECT is not generally accepted. Referring to ECT horror pictures of past psychiatry are cited. The language used is biased and discriminative. Referring to Defibrillation technical details are described and the language is neutral. The social representation of ECT is completely negative.

Florid psychopathology in patients receiving shocks from implanted cardioverter-defibrillators

OBJECTIVES

To increase awareness of the potential for disabling anxiety and depression in patients receiving shocks from implanted cardioverter-defibrillators (ICDs).

PATIENTS AND METHODS

ICDs are implanted in patients at this hospital for control of serious ventricular tachyarrhythmias inadequately controlled by drug treatment, who are unsuitable for map guided antiarrhythmic surgery. All are reviewed regularly at a dedicated ICD clinic and are advised to make contact between visits if they experience shocks. Symptoms of anxiety or depression were not actively sought, nor was a patient support group operating at the time of this data collection. When overt psychopathology was identified, patients were referred to a designated psychiatrist for management.

RESULTS

Over a six year period, six (17%) of 35 patients with ICDs developed florid psychiatric problems after experiencing shocks. None had premorbid psychiatric predisposition. Of the six patients suffering severe psychiatric problems, four were men, their age range was 30-63 years, and left ventricular ejection fraction was 18-40%. All shocks were appropriate for clinical arrhythmias and ranged in frequency from two in six months to 111 in 24 hours. All six patients manifested severe anxiety, focused on fear of future shocks. Depression was also evident in three patients and two had become housebound. All responded within weeks to anxiolytic or antidepressant drugs, combined with relaxation and cognitive therapies. Ongoing psychiatric therapy was refused by one patient, and was required for between three and 18 months in the remainder. One patient died and one received a cardiac transplant during the follow up period (median 27.5 months, range 8-43).

CONCLUSIONS

Because ICD implantation occurs against a complex medical background with inevitable psychological stress, all such patients should be considered at high risk for developing psychopathology.

Standardized assessment of psychological well-being and quality-of-life in patients with implanted defibrillators

The ICD has become a standard treatment for patients with malignant arrhythmias. Despite its benefits it may cause additional discomfort to the patients. Thus, quality-of-life needs to be assessed in these patients. Previous studies have used only small samples or unstandardized measures of quality-of-life that do not allow comparisons with other patient groups. The present study used standardized questionnaires for a cross-sectional assessment of psychological well-being and quality-of-life in ICD patients and to compare them to a similar group of coronary artery disease (CAD) patients without ICD. Overall, quality-of-life did not differ between both groups, ICD patients being less anxious than the CAD group. With increasing numbers of ICD shocks, however, the percentage of psychologically distressed ICD patients rose from 10% to > 50%. Psychologically distressed patients had significantly worse scores on most of the quality-of-life subscales, showed less treatment satisfaction, and more negative attitudes. It is concluded that ICD patients have an acceptable mean quality-of-life and low mean anxiety. However, a relevant subgroup of about 15%, especially patients with frequent shocks, experience psychological distress and reduced quality-of-life and should receive special care.

Knowledge and attitude of nurses on medical wards to defibrillation

We questioned 112 qualified nurses working on general medical wards about their resuscitation experience and knowledge of ECG interpretation and defibrillation. Although all but two of them had been formally trained in basic cardiopulmonary resuscitation (CPR) only 16 had received any training in the last six months. Seventy-five per cent of nurses were involved in CPR as first responders but only 18% had used a defibrillator during a cardiac arrest. Identification of ECG rhythms and practical knowledge about defibrillation was encouraging despite the lack of formal training in this field. Almost every one of the nurses would be willing to receive training in advanced cardiac life support. The responses to this inquiry suggest that nurses on medical wards are enthusiastic about advanced cardiac life support and already have some basic practical knowledge. Appropriate training (and retraining) of nursing staff should improve the outcome of resuscitation efforts on medical wards.

Efficacy and safety of transcutaneous low-impedance cardiac pacing in human volunteers using conventional polymeric defibrillation pads

STUDY OBJECTIVES

To assess the safety and efficacy of transcutaneous cardiac pacing using low-impedance defibrillation-type, self-adhesive polymer electrode pads positioned in the same anatomic sites typical of such pad placement in emergency defibrillation attempts.

DESIGN

Prospective, randomized, single-blinded normal subject investigation.

METHODS

Thirty healthy unmedicated adult volunteers of both sexes were paced transcutaneously to the threshold of capture and beyond by an intensity factor of 125%. A commercial defibrillator-pacer operating in demand mode had its rate set-point higher than the subjects' base-line rate by 125%. Threshold was established as the pulse current required to effect 75% captured beats. Pacing was continued at the 125% level for two minutes, during which subjective discomfort levels were recorded on a 1-to-5 pain scale.

RESULTS

All subjects but one were able to complete the study as designed. The single exception complained of intolerable pain early in the two-minute trial. Capture current had a mean value of 80 mA while the pain assessment averaged 3.2 on our five-point scale. No subject showed any untoward cardiovascular effects either during or after the study.

CONCLUSION

In normal human volunteers, transcutaneous cardiac pacing with low-impedance polymer pad electrodes is safe. By extrapolation from this study population, it is sufficiently effective to accommodate successfully the vast majority of clinical circumstances likely to be encountered in emergency medicine.

Refusal of implantable cardioverter defibrillator generator replacement: the nurse's role

An adult patient who is conscious and mentally competent has the right to refuse any medical or surgical procedure even when the best medical opinion deems it necessary for life. The doctrine of informed consent is grounded on the premise that a physician's judgment is subservient to the patient's right to self-determination. Some suggestions for the future are offered. It may be beneficial to have a formal doctrine of informed refusal incorporated into the existing system of informed consent thus having patients sign a refusal of treatment form just as they sign a form consenting to treatment. Even if the physician and patient share an ideal relationship that includes mutual respect and participation in decision making, the consent to treatment or refusal of treatment should be documented both on a form and in the physician's own words in the patient record to avoid any discrepancies that may arise later. Items that may eventually be added to the list of requirements for informed consent or refusal include the impact of the treatment or procedure on the patient's job or family situation, impact on quality of life, and the potential long-term cost to the patient or to public or private health care payers.

Living with recurrent ventricular dysrhythmias

The number of patients who live with recurrent ventricular dysrhythmias is increasing as medical advances such as pharmacologic and electrical therapies decrease mortality rates in this population. As a result, nurses frequently encounter patients who are trying to learn to live with chronic aspects of recurrent life-threatening dysrhythmias. The findings of this study provide an important beginning description of strategies used by patients to address their concerns. The RVD patients in this study reported using a variety of strategies to manage their physiologic and psychosocial concerns. Their responses described a continuum of strategies to handle concerns that ranged from "compensate for the concern" to "unable to handle the concern." These findings suggest several implications for nursing. Careful assessment of all patients with RVD is appropriate to detect areas where patients perceive a need for additional strategies to manage their concerns, require support for existing self-reliance strategies, and need identification of additional nursing interventions. Individualized or group programs may be appropriate interventions to assist some patients. Strategies to support patients who report an inability to manage specific concerns need clarification. Ideally, as further research defines the processes patients with RVD use to manage their concerns, high-risk patients can be discovered and provided with interventions to promote their adjustment to living with life-threatening dysrhythmias.

Anxiety and depression in patients with life-threatening ventricular arrhythmias: impact of the implantable cardioverter-defibrillator

In order to assess the psychological responses to the automatic implantable cardioverter-defibrillator (AICD), 18 patients with a history of life-threatening ventricular arrhythmias were requested to complete the Spielberger State-Trait Anxiety Inventory and the Beck Depression Inventory. The patients were divided into three groups of six and matched for age, sex, underlying cardiac disease, ejection fraction, and NYHA Functional Classification. Group I had experienced conscious discharges from the AICD, group II had the AICD but without discharges, and group III without the AICD were treated with antiarrhythmic medications alone based on electrophysiological guided testing. Patients with the AICD were also requested to complete a questionnaire directed specifically at their experiences with the AICD. All of the 18 patients completed the study responses and results were analyzed by blinded review. There were no significant differences in anxiety and depression scores in the three groups studied, nor any significant differences in responses to the questionnaire in group I versus group II. One patient in group I reported experiencing adverse psychological responses to the AICD. Although there appears to be no significant differences in psychological responses as a result of the AICD implantation in patients with life-threatening ventricular arrhythmias, further study with larger patient groups is needed to identify and support patients who may develop adverse responses to the AICD.

Patient and spouse acceptance and adaptation to implantable cardioverter defibrillators

Although electrophysiologic devices have been available since 1932 for managing sudden cardiac death, it was not until 1980 that the predecessor to the automatic implantable cardioverter defibrillator was introduced. Subsequently, questions about psychosocial adaptation have prevented wide acceptance of these devices. To study this issue, 69 patients with treatment-resistant ventricular arrhythmias were sent a questionnaire following cardioverter implantation; spouses also received questionnaires. Of these, 42 patients and 38 spouses completed and returned questionnaires. The questionnaire was designed to elucidate psychosocial adaptation. Results suggest that patients and couples adapt to the automatic implantable cardioverter defibrillators adequately, but not without some specific reservations.

Observations of a support group for automatic implantable cardioverter-defibrillator recipients and their spouses

We studied the use of an 8-week group support intervention with recipients of automatic inplantable cardioverter-defibrillators (AICDs) and evaluated the effect of this treatment on both patients and spouses. Patients attending the Rhode Island Hospital Arrhythmia Clinic formed the study population. Six patients and their spouses formed the treatment group. Six patients living a distance (greater than 25 miles) from the hospital who were not able to attend the sessions formed a natural comparison group. Outcome was reported by a descriptive analysis of the group experience and assessment of changes in role functioning and psychologic adaptation after the intervention. Study results supported our hypothesis that group therapy was an effective treatment modality in promoting positive adjustment of patients to the AICD device. Furthermore, trends emerged suggesting positive shifts in both role functioning and psychologic adjustment in patients attending group sessions. These findings suggest that group therapy is a useful method of providing support and education for individuals receiving the AICD device.

Treatment of anxiety associated with electrophysiologic studies

Programmed electrical stimulation, also known as electrophysiologic studies (EPS), is a cardiologic technique used to help guide physicians in their management of selected patients with cardiac arrhythmias. Data are presented for 14 consecutive patients undergoing EPS seen in psychiatric consultation who had a diagnosis related to anxious mood. Successful management strategies, which evolved from work with these patients, included psychologic approaches (supportive psychotherapy and education) and psychopharmacologic agents (most commonly alprazolam). EPS and related physiologic aspects of anxiety and stress are briefly reviewed.