Reducing mortality with device therapy in heart failure patients without ventricular arrhythmias

Use of device therapy to prevent sudden cardiac death in patients with heart failure is expanding on the basis of evidence from recent clinical trials. Three multicenter prospective clinical trials-Sudden Cardiac Death in Heart Failure (SCD-HeFT); Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION); and Cardiac Resynchronization-Heart Failure (CARE-HF)-were conducted to determine the effectiveness of devices in reducing mortality in patients with heart failure who did not have a history of ventricular arrhythmias. The 3 trials varied in the devices used, the population of patients included, and the study designs. In SCD-HeFT, implantable cardioverter defibrillators were more effective than pharmacological therapy in preventing mortality among patients with mild to moderate heart failure. In COMPANION, cardiac resynchronization therapy alone and cardiac resynchronization therapy plus an implantable cardioverter defibrillator were more effective than optimal drug treatment in reducing morbidity and all-cause mortality in patients with moderate to severe heart failure. In CARE-HF, cardiac resynchronization therapy alone was more effective than optimal drug treatment in reducing all-cause mortality in patients with moderate to severe heart failure. No direct comparison of the devices used has been done. These 3 clinical trials provide clear evidence that device therapy is beneficial for some patients with heart failure, even patients who do not have a history of ventricular arrhythmia.

Reducing Mortality With Device Therapy in Heart Failure Patients Without Ventricular Arrhythmias

Use of device therapy to prevent sudden cardiac death in patients with heart failure is expanding on the basis of evidence from recent clinical trials. Three multicenter prospective clinical trials—Sudden Cardiac Death in Heart Failure (SCD-HeFT); Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION); and Cardiac Resynchronization-Heart Failure (CARE-HF)—were conducted to determine the effectiveness of devices in reducing mortality in patients with heart failure who did not have a history of ventricular arrhythmias. The 3 trials varied in the devices used, the population of patients included, and the study designs. In SCD-HeFT, implantable cardioverter defibrillators were more effective than pharmacological therapy in preventing mortality among patients with mild to moderate heart failure. In COMPANION, cardiac resynchronization therapy alone and cardiac resynchronization therapy plus an implantable cardioverter defibrillator were more effective than optimal drug treatment in reducing morbidity and all-cause mortality in patients with moderate to severe heart failure. In CARE-HF, cardiac resynchronization therapy alone was more effective than optimal drug treatment in reducing all-cause mortality in patients with moderate to severe heart failure. No direct comparison of the devices used has been done. These 3 clinical trials provide clear evidence that device therapy is beneficial for some patients with heart failure, even patients who do not have a history of ventricular arrhythmia.

Changes in psychosocial distress in outpatients with heart failure with implantable cardioverter defibrillators

Patients given implantable cardioverter defibrillators (ICDs) after arrhythmic events or sudden cardiac arrest (SCA) experience psychosocial distress. ICDs now are inserted for the primary prevention of SCA in patients with heart failure; the psychosocial impact of ICDs on patients with heart failure is unknown. Changes in psychosocial status in these ICD recipients were examined. ICD recipients (n = 57) completed depression, anxiety, and social support inventories every 6 months for up to 2 years. Initially, 35% of recipients were depressed and 45% of recipients were anxious. In linear mixed models, depression decreased over time overall but increased in those who experienced ICD shocks. Anxiety decreased in New York Heart Association class III ICD recipients but not in class II ICD recipients. Decreases in social support were related to age: the younger the patient the greater the decrease. A significant proportion of ICD recipients were depressed or anxious, or had diminished social support even after 2 years. Investigation of strategies to improve ICD recipients' psychosocial status is warranted.

Promoting heart health in women: a workplace intervention to improve knowledge and perceptions of susceptibility to heart disease

The purpose of this study was to evaluate the effectiveness of a 5-week, 1 hour per week heart disease prevention program for sedentary female municipal workers with known heart disease risk factors. The program was designed to improve participants' knowledge and perceptions of their personal susceptibility to heart disease. In targeting an ethnically diverse, lower income working population, the researchers also sought to contribute to one of the goals of Healthy People 2010, the elimination of health disparities, specifically the reduction of health disparities in heart disease by 25% by the year 2010. A one-group, repeated measures, quasi-experimental design was employed. Forty-eight women 25 to 66 years old responded to the solicitation and participated in the program. Seventy-five percent were African American, 23% were White, and 2% were Latino. Participants completed a 33-item heart disease knowledge questionnaire, demographic questions, and a single visual analog scale statement to assess perceived susceptibility. Fifty-eight percent of the participants improved their knowledge of heart disease and 50% of the participants increased their perception of susceptibility to heart disease from pre- to post-intervention. The greatest improvement in knowledge and awareness of susceptibility occurred for those with limited knowledge and low perceptions of susceptibility. The gains from this workplace health education project for largely minority female municipal workers were modest, but notable. A workplace health education program for women targeted at increasing their knowledge of heart disease may also increase their perceptions of susceptibility to heart disease.

Korean version of the Revised Caregiving Appraisal Scale: a translation and validation study

AIM

This paper is a report of a study to examine the reliability and validity of a Korean version of the Revised Caregiving Appraisal Scale with Korean caregivers of older stroke survivors.

BACKGROUND

The Revised Caregiving Appraisal Scale was developed in the United States of America for an American English-speaking population to measure primary caregivers' appraisals of potential stressors and the efficacy of their coping efforts related to caregiving experiences.

METHODS

Using the back-translation method, the instrument was translated into Korean. The Korean version of the Revised Caregiving Appraisal Scale was self-administered by 147 primary family caregivers recruited from three outpatient clinics and two home health agencies in Korea. The study was conducted in 2005.

RESULTS

In this sample, Cronbach's alpha for the total scale was 0.86. Reliability coefficients for each of the five subscales ranged from 0.40 to 0.85. Two subscales, burden and satisfaction, showed good reliability; one subscale, impact, showed marginally acceptable reliability; two subscales, mastery and demand, had low reliability. Principal components factor analysis of the Korean version of the Revised Caregiving Appraisal Scale yielded six factors. Except for the mastery domain, which was divided into two factors, the other factors were similar to those in the original scale.

CONCLUSION

The Korean version of the Revised Caregiving Appraisal Scale had adequate reliability and validity in a sample of Korean caregivers of stroke survivors. It can be used to assess the impact of caregiving and interventions on Korean caregiver attitudes. Further studies are needed with different categories of caregiver.

The Fas ligand intracellular domain is released by ADAM10 and SPPL2a cleavage in T-cells

Fas ligand (FasL) is a type II transmembrane protein belonging to the tumor necrosis factor family. Its binding to the cognate Fas receptor triggers the apoptosis that plays a pivotal role in the maintenance of immune system homeostasis. The cell death-inducing property of FasL has been associated with its extracellular domain, which can be cleaved off by metalloprotease activity to produce soluble FasL. The fate of the remaining membrane-anchored N-terminal part of the FasL molecule has not been determined. Here we show that post-translational processing of overexpressed and endogenous FasL in T-cells by the disintegrin and metalloprotease ADAM10 generates a 17-kDa N-terminal fragment, which lacks the receptor-binding extracellular domain. This FasL remnant is membrane anchored and further processed by SPPL2a, a member of the signal peptide peptidase-like family of intramembrane-cleaving proteases. SPPL2a cleavage liberates a smaller and highly unstable fragment mainly containing the intracellular FasL domain (FasL ICD). We show that this fragment translocates to the nucleus and is capable of inhibiting gene transcription. With ADAM10 and SPPL2a we have identified two proteases implicated in FasL processing and release of the FasL ICD, which has been shown to be important for retrograde FasL signaling.

Quality of life and psychological status of patients with implantable cardioverter defibrillators

INTRODUCTION

Implantable cardioverter defibrillators (ICDs) are effective at reducing mortality in patients at high risk for sudden cardiac death (SCD) but can cause psychological distress and reduce quality of life (QOL). The full benefits of ICDs can only be achieved when the patient's QOL and psychological status are maintained. We examined psychological status and QOL post ICD implantation; the relationship of psychological status to QOL; the relationship of time since implantation to psychological status and QOL; and the relationship of time since ICD implantation and age of patient to these variables.

METHODS AND RESULTS

A cross-sectional self-administered assessment of QOL, depression, anxiety, demographic characteristics and cardiovascular health history of patients (n = 48) who had received ICDs within the past 10 years at an urban hospital. Patients who had ICDs for longer experienced worse depression and QOL. Patients who were younger had worse depression, anxiety, and QOL. The combination of anxiety, depression, age, and time since ICD implant significantly predicted overall QOL and the psychosocial and physical dimensions of QOL explaining 55.5, 54, and 34.9% of the variance, respectively.

CONCLUSION

Younger ICD patients are at highest risk for psychological distress and poor QOL. Longitudinal research would facilitate determination of the trajectory of changes in psychological status and QOL over the duration of the ICD experience.

Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality

OBJECTIVES

The Psychosocial Factors Outcome Study (PFOS) investigated the prevalence of depression and anxiety and the relationship of psychosocial factors to mortality in outpatients with heart failure (HF).

BACKGROUND

Considerable evidence links psychosocial factors to coronary heart disease mortality and sudden cardiac death (SCD). The contribution of psychosocial factors independent of disease severity to HF outpatient mortality is not well elucidated.

METHODS

Patients (N = 153) from 20 Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) sites participated in the PFOS. SCD-HeFT provided demographic, medical history, and cardiac data. Participants completed questionnaires to assess psychosocial status at PFOS entry.

RESULTS

Depression and anxiety were common in HF outpatients (36% Beck Depression Inventory-II > or = 13; 45% State Trait Anxiety Inventory > or = 40). Depression, anxiety, and social support amount did not differ in the SCD-HeFT treatment groups: implantable cardioverter defibrillator, amiodarone, and placebo medication. Fifteen (9.8%) patients died during mean follow-up at 23.6 months (SD = 8.2). In Cox regression controlling for treatment, depression, anxiety, and social isolation separately predicted mortality; perceived HF-specific functional status did not. Depression (ln) [P = .04, hazard ratio (HR) = 1.81] and social isolation (P = .04, HR = 2.25), but not anxiety, predicted mortality independent of demographics, clinical predictors, and treatment. When simultaneously including significant demographic, clinical, and psychosocial predictors and treatment groups, depression (ln) (P = .022, HR = 2.2) and social isolation (P = .094, HR = 1.75) predicted mortality. All-cause mortality was 12% for depressed patients and 9% for others.

CONCLUSION

This study finds a high prevalence of anxiety and confirms the high prevalence of depression in the HF outpatient population. Depression and social isolation predicted mortality independent of demographic and clinical status in HF outpatients.

Quality of Life and Psychological Status of Patients With Implantable Cardioverter Defibrillators

• Background Implantable cardioverter defibrillators reduce mortality in patients at high risk for sudden cardiac death and in patients with heart failure. Patients with defibrillators often experience psychological distress and poor quality of life, which can potentiate pathological processes that increase the risk for sudden cardiac death. To achieve the full benefits of the defibrillators, patients must maintain their psychological status and quality of life.

• Objectives To review the research on psychological status and quality of life of patients with implantable cardioverter defibrillators and suggest nursing interventions to improve the patients’ health.

• Method Searches of PubMed were used to find articles on depression, anxiety, and quality of life in patients with implantable cardioverter defibrillators.

• Results Poor quality of life is associated with anxiety and depression in patients with implantable cardioverter defibrillators. Discharges of the devices have adverse consequences for patients’ psychological status and quality of life. Younger patients are at highest risk for psychological distress and poor quality of life after implantation. Longitudinal research would facilitate determining the course of the changes in psychological status and quality of life during the time patients have the defibrillators. More intensive intervention may be necessary for the most vulnerable recipients: patients who are young, have experienced shocks, and are in psychological distress.

• Conclusions Poor quality of life and depression are common in patients with implantable cardioverter defibrillators. Nursing interventions to reduce psychological distress and improve quality of life may reduce morbidity and mortality in these patients. Additional research is needed to determine effective interventions.

Quality of life and psychological status of patients with implantable cardioverter defibrillators

BACKGROUND

Implantable cardioverter defibrillators reduce mortality in patients at high risk for sudden cardiac death and in patients with heart failure. Patients with defibrillators often experience psychological distress and poor quality of life, which can potentiate pathological processes that increase the risk for sudden cardiac death. To achieve the full benefits of the defibrillators, patients must maintain their psychological status and quality of life.

OBJECTIVES

To review the research on psychological status and quality of life of patients with implantable cardioverter defibrillators and suggest nursing interventions to improve the patients' health.

METHOD

Searches of PubMed were used to find articles on depression, anxiety, and quality of life in patients with implantable cardioverter defibrillators.

RESULTS

Poor quality of life is associated with anxiety and depression in patients with implantable cardioverter defibrillators. Discharges of the devices have adverse consequences for patients' psychological status and quality of life. Younger patients are at highest risk for psychological distress and poor quality of life after implantation. Longitudinal research would facilitate determining the course of the changes in psychological status and quality of life during the time patients have the defibrillators. More intensive intervention may be necessary for the most vulnerable recipients: patients who are young, have experienced shocks, and are in psychological distress.

CONCLUSIONS

Poor quality of life and depression are common in patients with implantable cardioverter defibrillators. Nursing interventions to reduce psychological distress and improve quality of life may reduce morbidity and mortality in these patients. Additional research is needed to determine effective interventions.

Contracts, covenants and advance care planning: an empirical study of the moral obligations of patient and proxy

Previously we had speculated that the patient-proxy relationship existed on a contractual to covenantal continuum. In order to assess this hypothesis, and to better understand the moral obligations of the patient-proxy relationship, we surveyed 50 patient-proxy pairs as well as 52 individuals who had acted as proxies for someone who had died. Using structured vignettes representative of three distinct disease trajectories (cancer, acute stroke, and congestive heart failure), we assessed whether respondents believed that proxies should follow explicit instructions regarding life-sustaining therapy and act contractually or whether more discretionary or covenantal judgments were ethically permissible. Additional variables included the valence of initial patient instructions--for example, "to do nothing" or "to do everything"--as well as the quality of information available to the proxy. Responses were graded on a contractual to covenantal continuum using a modified Likert scale employing a prospectively scored survey instrument. Our data indicate that the patient-proxy relationship exists on a contractual to covenantal continuum and that variables such as disease trajectory, the clarity of prognosis, instructional valence, and the quality of patient instructions result in statistically significant differences in response. The use of interpretative or covenantal judgment was desired by patients and proxies when the prognosis was grim, even if initial instructions were to pursue more aggressive care. Nonetheless, there was a valence effect: patients and proxies intended that negative instructions to be left alone be heeded. These data suggest that the delegation of patient self-determination is morally complex. Advance care planning should take into account both the exercise of autonomy and the interpretative burdens assumed by the proxy. Patients and proxies think inductively and contextually. Neither group viewed deviation from patient instructions as a violation of the principal's autonomy. Instead of adhering to narrow notions of patient self-determination, respondents made nuanced and contextually informed moral judgments. These findings have implications for patient education as well as the legal norms that guide advance care planning.

Discussions about cognitive impairment in first medical visits: older patients' perceptions and preferences

Primary care physicians are the first medical contact for most patients with early-stage dementia. However, little is known about older patients' desire for discussions about cognitive problems or the frequency of discussions about cognitive status during primary care visits. To investigate this question, older patients and accompanying individuals were interviewed separately following the first visit with a primary care physician in an outpatient geriatric medical practice. Patients indicated that memory was discussed in 62 percent of visits. When memory was not discussed, almost one-third of patients stated that they would have wanted to discuss it. Physicians were more likely than patients to initiate discussions about memory. Patient factors, including age, gender, the presence of an accompanying individual, number of diagnoses, and the patient's statement that cognitive function was a main goal of the visit, were examined as predictors of the likelihood of discussion of memory during the first visit. Patients who identified discussing cognitive function as a goal of the visit were more likely to have a discussion about memory than those who did not.