The impact of the implantable cardioverter defibrillator on quality-of-life

Efficacy of antitachycardia pacing alert by remote monitoring of implantable cardioverter-defibrillators for out-of-hospital electrical storm

BACKGROUND

Remote monitoring (RM) has been shown to reduce all-cause mortality in patients with implantable cardioverter-defibrillators or cardiac resynchronization therapy defibrillators (ICD/CRT-D). Not all devices transmit an alert for antitachycardia pacing (ATP) therapy, and it is unknown whether differences of RM alert affect the outcomes of electrical storm (ES).

METHODS

We enrolled 42 patients with ICD/CRT-D whose out-of-hospital ES were detected by RM between 2013 and 2020. We divided their 54 episodes into two groups (ATP-alert-on; 22, ATP-alert-off; 32), and clinical outcomes were compared between the two groups.

RESULTS

In 35 of 54 episodes of ES, ventricular tachycardia (VT) could be terminated within 24 h of ES onset just by ATP (ATP-alert-on: 14, ATP-alert-off: 21); however, many patients subsequently received shock delivery for VT. Among the 35 episodes, only in ATP-alert-on group, seven patients were prompted to visit our hospital without ICD shock through confirmation of ES by ATP-alert. Episodes that led to shock delivery 24 h or longer after the ES onset were significantly less common in the ATP-alert-on group (ATP-alert-on: 1/14, ATP-alert-off: 9/21, p = .03). Although there were no significant differences in the number of shock deliveries between episodes in the two groups, the number of ATP deliveries were significantly fewer in the ATP-alert-on group (12[7-26] vs. 29[16-53] in ATP-alert-off group, p = .03). Multivariate logistic regression analyses showed that the only ATP-alert significantly reduced ATP deliveries (HR = 0.14, 95%CI = 0.04-0.57, p = .003).

CONCLUSION

Remote monitoring with an ATP-alert function during electrical storm may reduce appropriate ICD therapy through prompting early review.

VT ablation in geriatric patients with structural heart disease: Should there still be an age limit?

INTRODUCTION

This study sought to examine the feasibility and outcome of ablation of ventricular tachycardias (VTs) in a contemporary cohort of geriatric patients with structural heart disease (SHD).

BACKGROUND

Geriatric patients are often underrepresented in large studies. As frailty is becoming an increasing problem, we need to examine the best course of action for this population.

METHODS AND RESULTS

We investigated 68 SHD-patients ≥ 75 years old undergoing VT-ablation (men 88%, ischemic cardiomyopathy 77%, electrical storm 72%, mean left ventricular ejection fraction 31%) and divided the cohort into two groups: 75-79 years old (n = 51) and ≥80 years old (n = 17). The two groups showed similar results regarding noninducibility as ablation endpoint (p = .693), major procedure-related complications (p = .488), and VT-recurrence (p = .882) during the 39-month follow-up. At the end of the follow-up, 10 patients in the octogenarian group (59%) versus 16 patients of the other group (31%) died.

CONCLUSION

Geriatric patients with SHD including octogenarians showed similar results regarding procedural endpoints, freedom of VT, and major procedure-associated complications after VT-ablation. When ablation is indicated, age alone should not be an inhibiting factor to treat these patients.

Severe chronic kidney disease is associated with poor survival after initial CRT-defibrillator tachyarrhythmia therapy

BACKGROUND

Implantable cardioverter-defibrillator (ICD) recipients who receive appropriate device therapies have limited survival, and survival benefit in chronic kidney disease (CKD) has been questioned. We examined the association between CKD and survival after cardiac resynchronization therapy (CRT)-defibrillator tachyarrhythmia therapies.

METHODS

We compared overall survival after appropriate shocks or anti-tachycardia pacing in 439 CRT-defibrillator recipients with left ventricular ejection fraction (LVEF) ≤35%, non-right bundle-branch block QRS pattern, and QRS duration >130 ms according to glomerular filtration rate (GFR) at implant, including 31 patients with GFR ≤30, 164 patients with GFR 31-60, and 244 patients with GFR >60. At least one shock occurred in 302 patients (24 with GFR ≤30, 102 with GFR 31-60, and 176 with GFR >60). Serial echocardiograms were also compared.

RESULTS

Patients were followed 64 months (interquartile range [IQR]: 29-94) after implant, including 32 months (IQR: 12-61) after first therapy. Time to first therapy or shock was similar across GFR groups. However, survival after first therapy declined directly with declining GFR (P < .001), with median postshock survival of 90 days for GFR ≤30 (95% confidence of interval [CI]: 0-233), 612 days (95% CI: 365-859) for GFR 31-60, and 1672 days (95% CI: 1396-1948) for GFR >60. Declining GFR category, ischemic heart disease, diabetes, and increasing age were independently associated with increased postshock mortality. Echocardiographic response was similar across GFR groups and was not associated with post-therapy survival.

CONCLUSIONS

Survival after appropriate tachyarrhythmia therapies, particularly shocks, is attenuated in patients with GFR ≤30. This raises concern over potential lack of survival benefit conferred by CRT-defibrillators versus CRT-pacemakers in this population.

Impairment of Quality of Life among Patients with Wearable Cardioverter Defibrillator Therapy (LifeVest®): A Preliminary Study

Background

Wearable cardioverter defibrillator (WCD) therapy is feasible and safe in patients as a transient protection against sudden cardiac death (SCD). However, the impact of WCD therapy on quality of life (QoL) has not been studied.

Methods

In our single-centre study, 109 consecutive patients with a prescription of WCD were retrospectively analysed. Quality of life has been assessed by a standardized questionnaire (EQ-5D-3L, modified). Additionally, clinical baseline and follow-up data and recorded arrhythmic episodes were evaluated.

Results

Mean WCD therapy time was 56.2 (± 42.4) days, with a daily wear time of 19.7 (± 5) hours. A total of 3441 arrhythmia episodes were detected. Of these, 27 (1%) were adequate but did not require shock therapy. Likewise, no inadequate shock therapy occurred. WCD therapy negatively affected quality of life: 43% of patients reported mental health issues. 37% reported pain or discomfort. Self-care, usual activities, and mobility were restricted in 17%, 48%, and 36%, respectively. 29% were afraid of receiving shock therapy, and 48% suffered from sleep disturbance. However, 64% indicated having felt safe during WCD therapy. Accordingly, average quality of life was rated 70/100 points.

Conclusion

In our cohort, no SCD was prevented by WCD therapy. In contrast, in this preliminary study quality of life was reduced. Thus, careful recommendation of WCD therapy for high risk patients should be considered.

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.

Exploring the Patient's Experiences of Learning to Live with an Implantable Cardioverter Defibrillator (ICD) from One UK Centre: A Qualitative Study

BACKGROUND

International expansion of indications for implantable cardioverter defibrillator (ICD) implant means increasing numbers of patients with devices worldwide. However, smaller numbers of patients with ICDs in the UK has meant that clinical expertise available to care for this specialized group is limited. Whilst North American patients' experiences of living with an ICD are well documented, European perspectives remain underrepresented.

AIM

The aim of this study was to explore and describe patient's experiences around the time of their ICD device implant and after they returned home from one UK centre.

METHODS AND RESULTS

Eligible patients were recruited from one regional cardiothoracic centre and interviewed in their own homes using semi-structured schedules. Analysis of data elicited three themes; non-individualised nature of information, adjustments to living with the device and future outlook. Unique findings identified were; (a) concealment of concerns and symptoms; (b) funding issues; and (c) unavailability of appropriate support and advice during and after time in hospital.

CONCLUSION

Individualized care and support for these ICD patients appeared lacking according to respondents. Opportunities to discuss concerns appeared non-existent, which may indicate that UK patients are disadvantaged in the domain of psychological support compared with their European and North American counterparts. Findings remain tentative until explored with a larger, more representative and international sample.

Changes in Health Status, Psychological Distress, and Quality of Life in Implantable Cardioverter Defibrillator Recipients Between 6 Months and 1 Year After Implantation

Background: Living with an implantable cardioverter defibrillator (ICD) has positive health benefits but the impact on well-being and quality of life over a period of time has not been studied in depth. Aim: To follow patients prospectively over the first year and to compare the changes from time of ICD implantation, to 6 months and 1 year. Methods: Generalized linear models were used to assess changes through examination of health status (SF-36), psychological distress (POMS), and quality of life (QLI) scores. Results: There were 19 females (27%) and 51 males (73%) in the sample with a mean age of 64 years. There were significant improvements over time in 3 of the 8 sub-concepts of health status: role physical ( P<0.001), vitality ( P<0.013) and social functioning ( P<0.001). The Profile of Mood States revealed significantly less total psychological distress at 6 months with a non-significant leveling off or increase at 1 year. The quality of life index revealed no significant changes over time. Conclusions: The effects of living with an ICD are not well understood. Research should continue to identify the impact over time in this population and sub-groups so that health care providers can address the social and psychological needs of this population.

Partners of ICD Patients—An Exploratory Study of Their Experiences

BACKGROUND

The experiences of partners who care for and support the needs of a loved one with an implantable cardiac defibrillator (ICD) remain largely unknown within Europe.

AIMS

This study explored the nature of partner's experiences from the pre-ICD implantation phase up until a maximum of 20 months at home.

METHODS

Eight partners cohabiting with a recipient of an ICD were interviewed using a semistructured schedule. All interviews were transcribed and content analysed for emerging categories and themes.

FINDINGS

Four themes representing 11 categories conceptualised the partners' experiences, these included: Acknowledging the patient's need for the device, reactions to the device, safeguarding the patient, and returning to normality.

CONCLUSION

This qualitative study suggests that partners of ICD recipients progress through various difficult and adaptive stages when learning how best to support the patient. A point is reached when most are able to assume control and normalise their lives. This transformation is slow; however, to improve this process and empower partners, nurses should provide relevant information and include them in decisions affecting the patient. Further research into the unique needs of partners, which includes international perspectives, would be significant in developing practice and theory in this area.

End-of-life Heart Failure Care in the United States

Heart failure (HF) is increasingly common in the United States and is associated with a high degree of morbidity and mortality. As patients approach the end of life there is a significant increase in health care resource use. Patients with end-stage HF have a unique set of needs at the end of life, including symptoms such as dyspnea, uremia, and depression, as well as potentially deactivating implantable defibrillators and mechanical circulatory support devices. Improved palliative care services for patients with HF may improve quality of life and decrease health care resource use near the end of life.

Implantable cardioverter defibrillator shocks are prospective predictors of anxiety

OBJECTIVES

To examine the temporal contingency of anxiety and implantable cardioverter defibrillator (ICD) therapy (anti-tachycardia-pacing and shocks to prevent ventricular tachycardia and/or fibrillation).

BACKGROUND

It is under debate whether anxiety is a precursor and/or consequence of ICD-therapy.

METHODS

In a prospective longitudinal study, fifty-four patients undergoing first-time ICD-implantation were assessed for anxiety, frequency of ICD-shocks and anti-tachycardia-pacing up to two days before ICD-implantation (T0) and twelve months later (T1).

RESULTS

Anxiety at T0 did not predict frequency of ICD-shocks at T1, but ICD-shocks significantly predicted increased anxiety at T1. In contrast, anxiety at T0 and T1 was unrelated to frequency of anti-tachycardia-pacing. Effects remained stable when we controlled for potentially confounding variables (e.g. age, sex, cardiac health and depression at T0).

CONCLUSION

Our findings indicate that repeated ICD-shocks are a cause of anxiety in ICD-patients rather than a consequence, thus shock frequency should be minimized.

[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.

Phantom shocks unmasked: clinical data and proposed mechanism of memory reactivation of past traumatic shocks in patients with implantable cardioverter defibrillators

BACKGROUND

Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor.

METHODS

A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks.

RESULTS

Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms.

CONCLUSIONS

Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.

A comparison of anxiety, depression and quality of life between device shock and nonshock groups in implantable cardioverter defibrillator recipients

BACKGROUND

Using standardized scales, we assessed the point prevalence, the severity of anxiety and depressive disorders, and the quality of life (QOL) in implantable cardioverter defibrillator (ICD) recipients who received a device shock.

METHODS

Forty research subjects with device shocks (Group 1) and 25 without shocks (Group 2) were interviewed after ICD implantation using the Mini International Neuropsychiatric Interview (MINI), the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36).

RESULTS

The point prevalence of anxiety disorders was higher in Group 1 (37.5%) than in Group 2 (8%) (P=.009). Depressive symptoms scores were higher in Group 1 (4.75) than in Group 2 (2.24) (P=.04)), but the prevalence of depressive disorders or the anxiety scores were not significantly different. A positive correlation was found between the number of shocks and the depressive symptoms scores (P=.05, r=0.24); there was a negative correlation between the mental health subscore of the SF-36 and the number of shocks (r=-0.36, P=.003). The point prevalence of depressive disorders was higher in the group with congenital cardiac diseases (50%) than in the valvular (8%) and ischemic groups (23%) (P=.04), and the mental health composite summary score of the SF-36 was lower in this group (46.34) than in those with valvular and ischemic disease (56.09 and 52.61, respectively) (P=.03).

CONCLUSION

Exposure to shocks may lead to an increased risk of anxiety and depressive symptoms. Research subjects receiving a high number of shocks and research subjects with congenital cardiovascular diseases were at higher risk of depressive symptoms or at higher risk of poorer psychological aspects of QOL.

Psychological distress across the course of care: a case study from implantable cardioverter defibrillator to cardiac transplantation evaluation

The psychological distress of cardiac patients can complicate treatment or the recovery process. This case study presents a 47-year-old male recipient of an implantable cardioverter defibrillator who experienced multiple, consecutive shocks and subsequently developed anxiety and depressive difficulties. Psychological treatment to diminish these symptoms was employed. Despite declining cardiac function, the patient made significant progress in managing this negative affect. Subsequently, he was evaluated for cardiac transplant, and this treatment progress became critical evidence of his psychosocial suitability for transplant.

Examining the psychosocial impact of implantable cardioverter defibrillators: a literature review

BACKGROUND

The implantable cardioverter defibrillator (ICD) has proven to be superior to medications in treating potentially life-threatening ventricular arrhythmias, resulting in reduced mortality rates. Despite the number of patients receiving this therapy, its psychosocial impact is not well understood.

HYPOTHESIS

The purposes of this paper are (1) to review the available literature documenting the psychosocial impact of the ICD on patients, (2) to hypothesize possible mechanisms for this psychosocial impact, and (3) to suggest clinical risk profiles and indications for psychological consultation.

METHODS

Electronic and library searches (e.g., MEDLINE, PsychLit) were used to gather studies examining the psychosocial impact of the ICD. Only studies investigating psychosocial outcomes (e.g., psychological distress, quality of life, social and role functioning), either prospectively or cross-sectionally, were admitted into the review. No literature reviews or secondary sources were included.

RESULTS AND CONCLUSIONS

Current research suggests that ICD-specific fears and symptoms of anxiety (e.g., excessive worry, physiological arousal) are the most common psychological symptoms experienced by ICD recipients, with approximately 13-38% of recipients experiencing diagnosable levels of anxiety. Depressive symptoms are reported at rates that are generally consistent with other cardiac populations. Although the incidence of psychological disorders appears to be similar to that found in general cardiac populations, specific ICD-related concerns such as fear of shock, fear of device malfunction, fear of death, and fear of embarrassment have been identified. Selected psychological theories such as classical conditioning, learned helplessness, and a cognitive appraisal model help to explain the occurrence of psychological symptoms post implantation. Psychosocial adjustment risk profiles indicate that young ICD recipients and those with high discharge rates may experience the most adjustment difficulties.

Depressive coping is a predictor for emotional distress and poor quality of life in a German-Austrian sample of cardioverter-defibrillator implant recipients at 3 months and 1 year after implantation

OBJECTIVE

The implantable cardioverter defibrillator (ICD) has been proven to prolong the lives of patients with life-threatening ventricular arrhythmia. However, implant recipients must cope with numerous challenges. We studied the effects of specific coping strategies and the adaptability of coping in ICD implant recipients.

METHOD

This prospective study investigated the subjective well-being and objective disease course in 180 patients with life-threatening cardiac arrhythmias, who were recruited while awaiting implantation of a cardioverter defibrillator. Patients completed well-validated self-assessment questionnaires before implantation (T0), as well as 3 months (T1) and 1 year (T2) after implantation. In addition, cardiological findings were documented.

RESULTS

Depressive coping (range Beta, -0.36 to -0.58) was found to be a stable highly-significant predictor for low emotional well-being and quality of life. Active problem-oriented coping showed small positive influence (range Beta, 0.10 to 0.19). Employing a broad range of coping strategies was predictive of less emotional distress and better quality of life.

CONCLUSIONS

Depressive coping is a risk factor for emotional distress and poor quality of life after ICD implantation. Patients with this tendency should be identified early and offered supportive psychotherapy.

Why Cardioverter‐Defibrillator Implantation Might Not Be the Best Idea for Your Elderly Patient

Over the last decade, implantable cardioverter-defibrillators (ICDs) have become a part of mainstream clinical practice, with improvements in survival in a broad range of patients. Given the overall limited life expectancy of elderly patients, their frequent comorbidities, and the complications associated with ICD implantation, it may not be reasonable to expect results with ICD implantation in the elderly to be comparable to that found in the clinical trials. In this paper, the authors review the available scientific literature and discuss why mainstream ICD use in the elderly may not be advisable.

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.

Psychological implications of ICD implantation in a New Zealand population

AIMS

Previous studies have raised concerns about high levels of anxiety and depression in implanted cardioverter-defibrillator patients, and suggested that adverse psychological outcomes have been related to delivered therapy, age, and gender. This study aimed to assess the prevalence of anxiety and depression and to analyse quality-of-life in a New Zealand patient group.

METHODS AND RESULTS

We questioned 46 ICD and 49 pacemaker patients regarding device and treatment satisfaction, depression, anxiety (Hospital Anxiety and Depression Scale), and quality-of-life (SF 36). The prevalence of clinical depression and anxiety in the ICD group was 7 and 13%, respectively, and did not differ from the pacemaker group. ICD patients mean anxiety and depression scores did not differ from the pacemaker group, although more ICD patients had subclinical levels of anxiety. Quality-of-life scores were normal for all ICD patients with respect to both mental and physical component scores, and not different from the pacemaker group. Anxiety, depression, and quality-of-life scores were unrelated to time from implantation, delivered therapy, age, or gender. Overall, 93% of the ICD patients thought their device was worthwhile.

CONCLUSION

We found a lower than expected level of anxiety and depression in ICD patients, and suggest that this may be due in part to the small team approach adopted locally in the follow-up of this patient group.

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.

Effects of mobile telephones on the function of implantable cardioverter defibrillators

OBJECTIVE

We investigated whether mobile telephones affect the function of implantable cardioverter defibrillators (ICDs).

BACKGROUND

It is well known that electromagnetic fields can affect medical devices.

METHODS

The study included 43 patients with ventricular tachycardia and/or fibrillation treated with transvenous pectoral ICDs. Testing was done under continuous electrocardiograph monitoring under supervision of an ICD programmer. Initially, each patient was tested during spontaneous rhythm. Then the ICD was programmed to a pace rhythm higher than the patient's heart rate, and the tests were repeated at paced rhythm. In 7 patients, tests were performed during the implantation procedure as well. In 3 of the patients, only a single defibrillation zone was active. The other 40 patients had one or more active ventricular tachycardia zones. Two mobile phones (both GSM 900 MHz) were positioned 50 cm away from the implanted device in opposite directions and switched on. Communication was established between these phones, two investigators had a 20-second conversation, and then the phones were switched off. The same procedure was repeated at 30, 20, and 10 cm away from the implantation site, respectively. Finally, the procedure was performed with the antennae of both phones touching the device pocket. In the above-mentioned 7 cases where testing was done during implantation of the ICD, a call was made from one phone to the other, ringing occurred for 5 seconds, and then two investigators conversed while the device was implanted.

RESULTS

There was no change in the function of the ICDs during any of the phone testing procedures. In 5 cases, artifacts were noted on the surface electrocardiographic (ECG) screen of the programmer during the tests, but no such changes were observed on the simultaneous intracardiac ECGs.

CONCLUSION

The results of the study suggest that mobile phones have no effects on ICD function.

Characteristics associated with low treatment satisfaction in patients with implanted cardioverter defibrillators: results from the LICAD study

The evaluation of low treatment satisfaction (LTS) with an implanted cardioverter defibrillator (ICD) remains a neglected area of clinical research. However, a trustful attitude toward an ICD is crucial. Within the scope of ICD health technology assessment, we searched for predictors of LTS. Of 195 ICD patients enrolled (mean 59.8 years, standard deviation 12.6), 163 (83.6%) were men and 26 (16.4%) were women. We measured anxiety, helplessness, and depression with standardized instruments and LTS with 11 dichotomous items concerning a mistrustful attitude, a negative body image, and low appraisal. A total of 47 (24.1%) patients were considered as LTS patients. Multivariate logistic regression was used for assessment of LTS. Adjusted for age and survey, LTS was significantly more prevalent in depressed, anxious, and phobic patients. Multivariate logistic regression including medical and psychological covariates revealed the experience of > or =5 shocks with an odds ratio (OR) of 10.17 (95% CI 3.57-29.00, P < or = 0.001), being employed with an OR of 8.07 (95% CI 2.39-27.19, P < or = 0.001), and feelings of helplessness (OR 4.61, 95% CI 1.79-11.90, P < or = 0.002) as the most important predictors for LTS. Women had a slightly not significant effect on LTS. Age, educational status, and depression were not significant. LTS patients required more support for living with the ICD (P < or = 0.001). Thus, LTS serves as surrogate measure for deteriorated psychic health. Clinicians should be advised to identify LTS patients and to consider psychotherapeutic counseling for them.

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.

Psychological Disturbances, Adjustment, and the Development of Phantom Shocks in Patients With an Implantable Cardioverter Defibrillator

The implantable cardioverter defibrillator (ICD), approved for use in 1985, is used to treat potentially lethal ventricular arrhythmias by delivering an electrical impulse to the heart to convert the rhythm back to normal. Since that time, newer studies, such as MADIT II and SCD-HeFT, demonstrated the expanding utility of the ICD, which increases the likelihood of every clinician encountering a patient with an ICD. Patients with an ICD face psychological, physical, and social adjustments. Patients with an ICD, in general, have been shown to have high levels of anxiety, depression, and a sense of helplessness. A subset experiences a phenomenon of phantom shock, which may represent a manifestation of anxiety, depression, or other emotional disturbance. It is important to be aware of this phenomenon, as a phantom shock may either represent or contribute to the patient's maladjustment to the ICD. In lieu of specific screening and treatment options for phantom shock at present, we must use a general approach for recognizing patients experiencing this phenomenon.

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.

Do positive health expectations and optimism relate to quality-of-life outcomes for the patient with an implantable cardioverter defibrillator?

PURPOSE

Clinical trials with the implantable cardioverter defibrillator (ICD) have demonstrated desirable outcomes in terms of mortality and morbidity among patients with potentially lethal arrhythmias. This study examined the "resilience factors" of positive health expectations and global optimism prospectively using the general quality-of-life (QOL) scores of newly implanted ICD patients.

METHODS

The study enrolled 88 newly implanted ICD patients (mean age, 65.3 +/- 13.2 years; 83% male; 92% white) assessed 8 and 14 months after ICD implantation. A series of 2 x 2 factorial multivariate analyses of covariance were performed to examine the differences between baseline low versus high positive health expectations and baseline low versus high optimism in short- and long-term general QOL scores.

RESULTS

After control was used for ejection fraction (mean, 31%), the patients with baseline high positive health expectations reported better general health at a long-term follow-up assessment (P = .002). The patients with high optimism reported better mental health and social functioning at a short-term follow-up assessment (P =. 056), and this finding approached significance at a long-term follow-up assessment (P = .061).

CONCLUSIONS

Positive health expectations and optimism are differentially related to various components of QOL. Collectively, these two resilience factors may be targeted in future studies of interventions to improve QOL for ICD patients.

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.

Patients with an ICD can safely resume work in industrial facilities following simple screening for electromagnetic interference

Patients with ICDs are commonly advised to quit industrial jobs because of concerns that strong electromagnetic fields operating in the industrial environment might interfere with ICD functions. This study was done to assess interactions between industrial equipment and ICDs, and to devise a simple low risk screening protocol. We studied 18 patients carrying nine different ICD models who were met at their workplace by a clinical technician and were asked to walk through their workplace and perform typical duties while sensing status was monitored by listening to the ICD's beeper. All devices were interrogated at the completion of testing. At follow-up, patients were contacted by phone and were asked about employment status and history of ICD discharges or syncope. One hundred eighty-four contacts with 114 types of industrial equipment in 13 different industrial facilities (including 31 contacts with arc welding machines) were monitored. Interference with ICD's function occurred in only one contact (0.5%), when ICD therapy was temporarily suspended while a worker was attaching a huge electromagnet to a crane. At follow-up 46.0 +/- 6.0 months after testing, 7 patients (41%) are still holding the same job, 7 have retired because of reasons unrelated to their ICD, and 3 patients were transferred to a nonindustrial job. None of the patients had either an ICD shock or syncope during work. The use of a simple screening procedure can safely identify sources of electromagnetic interference that may affect ICD operation, and can predict long-term safety of working in an industrial workplace for ICD patients.

Fear of exercise and health-related quality of life in patients with an implantable cardioverter defibrillator

Several studies have reported improved survival rates thanks to the use of an implantable cardioverter defibrillator (ICD) in the treatment of patients with life-threatening arrhythmia. However, the effects of the ICD on health-related quality of life (HR-QoL) of these patients are not clear. The aim of this study is to describe HR-QoL and fear of exercise in ICD patients. Eighty-nine ICD patients from the University Hospital in Groningen, the Netherlands, participated in this study. HR-QoL was measured using the Rand-36 and the Quality of Life After Myocardial Infarction Dutch language version questionnaires. Fear of exercise was measured using the Tampa Scale for Kinesiophobia, Dutch version and the Fear Avoidance Beliefs Questionnaire, Dutch version. Association between outcome variables was analysed by linear regression analyses. Study results show that the HR-QoL of patients with ICDs in our study population is significantly worse than that of normal healthy people. Furthermore, fear of exercise is negatively associated with HR-QoL corrected for sex, age and number of years living with an ICD. After implantation of the ICD, patients with a clear fear of exercise should be identified and interventions should be considered in order to increase their HR-QoL.

Exaggerated electrodermal startle responses after intracardiac shock discharges in patients with implanted cardioverter defibrillators

OBJECTIVE

We studied whether repetitive intracardiac shock discharges of implantable cardioverter defibrillators (ICDs) provoke an enduring enhancement of startle responses.

METHODS

The study population comprised 134 patients with an ICD. Among those, 67 patients had experienced shock delivery. Thirty-five patients had received five or more shocks. We used the startle reflex paradigm, which consisted of 15 acoustic stimuli (95 dB, 1000 Hz, 500 ms duration). Skin conductance response was measured using a constant 0.5 V through 8-mm electrodes placed on each subject's nondominant palm. Response magnitude was calculated by subtracting the baseline response level of the 2 seconds immediately preceding tone onset from the maximum response level within 1 to 4 seconds after tone onset. The left orbicularis oculi electromyogram (EMG) response was calculated by subtracting the mean EMG level during the 2 seconds immediately preceding tone onset from the highest EMG level measured within 40 to 200 ms after tone onset. Habituation was defined by the response slope of the regression equation and by the number of trials required to reach the nonresponse criterion.

RESULTS

Although EMG response measures of magnitude and habituation failed to yield differences between study groups, patients who had experienced five or more ICD shocks exhibited a significantly larger skin conductance response magnitude in comparison to the patients who had experienced fewer than five shocks (median, interquartile range: 0.364, 0.209-0.618 vs. 0.512, 0.375-0.791; Mann-Whitney U test, p =.007). Poorer habituation in the group with five or more shocks in comparison with the low shock group was confirmed both by the number of trials needed to reach the nonresponse criterion (median, interquartile range: 10, 5-14 vs. 5, 2-13; p =.003) and by the response slope (median, interquartile range: 0.209, 0.116-0.274 vs. 0.262, 0.181-0.332; p =.008). After controlling for potential confounding factors (age, anxiety, aversiveness of stimuli, time since last shock experience, and use of beta-adrenoceptor antagonists), intracardiac shock discharges had the strongest impact on augmented skin conductance response magnitude (adjusted odds ratio = 3.0, 95% confidence interval = 1.3-7.2, p =.01) and impaired habituation (adjusted odds ratio = 2.8, 95% confidence interval = 1.2-6.3; p =.015).

CONCLUSIONS

Intracardiac shock discharges are associated with augmented skin conductance responses and slower habituation, indicating sustained sympathetic arousability, which is presumably centrally mediated.

Psychological reactions among family members of patients with implantable defibrillators

OBJECTIVE

To describe psychological reactions among family members of patients receiving an implantable cardioverter/defibrillator (ICD) during the first 9 months after implantation.

METHODS

Eighty-two family members (age 56+/-12 years, 74 percent female, 79 percent married, 88 percent Caucasian) of ICD patients completed questionnaires regarding their mood (Profile of Mood State), cognitive illness appraisals (Meaning of Illness Questionnaire) and coping strategies (Jalowiec Coping Scale) prior to ICD implantation, and as well as 1 and 9 months postoperatively.

RESULTS

Total mood disturbance score (TMD), threat appraisal, and emotion- and problem-focused coping were highest prior to ICD implantation, and decreased during the first postoperative month showing stable values thereafter. There was no change in challenge appraisal. Multiple regression analysis found that the use of psychotropic drugs (anxiolytics, sedatives; Beta = .25), emotion-focused coping (Beta = .37), and challenge appraisal (Beta =-.21) at 1 month accounted for 26 percent of variance in TMD at 9 mon ths.

CONCLUSION

A spouse's ICD implantation is a major stressful event for family members leading to a diminished mood state prior ICD implantation. Reduction in emotion-focused coping and the use of challenge appraisal may improve mood state in family members of ICD patients during early follow-up.

Australian implantable cardiac defibrillator recipients: quality-of-life issues

Implantable cardioverter defibrillators (ICDs) have become a well-established therapy for people experiencing potentially lethal dysrhythmias. Australian recipients' quality of life and adjustment to the device over time, device-related complications, shock and associated sensations, and potential sequelae have not been widely explored. This paper reports a longitudinal prospective study of Australian ICD recipients (n = 74) to determine their responses to the device, health-related quality of life over time and shock experiences. A questionnaire designed for the study and the Medical Outcomes Trust Quality of Life Instrument, the SF36, were completed by recipients prior to and at 3 and 12 months post insertion. Results show that quality of life decreased for general health and social function between 3 and 12 months. Nearly half (49%) of the recipients received shocks within 12 months and the majority (92%) of these experienced sequelae that could make driving hazardous. Half of the population (49%) were driving at 3 months and 69% by 12 months, including 67% of those who had been shocked. Twenty-seven percent were hospitalized with device-related complications. Driving, the shock experience and rehospitalization, the shock experience and driving behaviour are significant issues for those with the implanted device. While it is a limitation of the study that partners and carers were not included, these findings will also be of interest to them.

Quality of life in the antiarrhythmics versus implantable defibrillators trial: impact of therapy and influence of adverse symptoms and defibrillator shocks

BACKGROUND

Implantable cardioverter defibrillator (ICD) use reduces mortality in patients with serious ventricular arrhythmias compared with antiarrhythmic drug (AAD) use. However, the relative impact of these therapies on self-perceived quality of life (QoL) is unknown.

METHODS AND RESULTS

Three self-administered instruments were used to measure generic and disease-specific QoL in Antiarrhythmics Versus Implantable Defibrillators trial participants. Generalized linear models were used to assess the relationships between self-perceived QoL and treatment (AAD versus ICD) and adverse symptoms and ICD shocks. To minimize the impact of missing data, only patients surviving 1 year were included in the primary analyses. Baseline characteristics among QoL participants (n=905) and nonparticipants (n=111) were similar, but participants who survived 1 year (n=800) were healthier at baseline than nonsurvivors (n=105). Of the 800 patients in the primary analysis, characteristics of those randomized to AAD (n=384) versus ICD (n=416) were similar. Overall, ICD and AAD use were associated with similar alterations in QoL. The development of sporadic shocks and adverse symptoms were each associated with reduced physical functioning and mental well-being and increased concerns among ICD recipients, whereas development of adverse symptoms was associated with reduced physical functioning and increased concerns among AAD recipients.

CONCLUSIONS

ICD and AAD therapy are associated with similar alterations in self-perceived QoL over 1-year follow-up. Adverse symptoms were associated with reduced self-perceived QoL in both groups, and sporadic shocks were associated with reduced QoL in ICD recipients.

Living with an implantable cardioverter-defibrillator: a review of the current literature related to psychosocial factors

Sudden cardiac death (SCD) is responsible for 300,000 deaths annually. Lethal ventricular dysrhythmias account for the majority of SCDs. Implantable cardioverter-defibrillators (ICDs) are the emerging treatment for lethal dysrhythmias. Although reductions in SCD mortality with ICDs are clear, the psychologic and social consequences of these devices reveal a mixed success. Patients with ICDs have high levels of anxiety and depressive symptoms. Conversely, most studies of quality of life in patients with ICDs report that the device is well accepted despite fears of being shocked. The ICD shocks are a unique aspect of treatment and have the potential to cause psychologic distress. Nursing needs to provide care from a holistic perspective. Support groups provide reassurance and allow patients to discuss expectations and fears related to the ICD. Research needs to be conducted to explore the impact of these devices on the lives of patients and their families.

Implantable Cardioverter Defibrillator: Current Progress and Management

With greater technologic advances during the past decade, use of the implantable cardioverter defibrillator (ICD) has increased to more than 200,000 implants worldwide to date. Indications for ICD implant have expanded to include both patients who have survived sudden cardiac death (secondary prevention of cardiac arrest) and those who are at high risk for experiencing lethal arrhythmias (primary prevention of cardiac ar rest). Thus, it is likely that physicians will encounter defibrillators in their clinical practice and must be familiar with their indications for implant, basic opera tion, and long-term management of devices. Several prospective clinical trials have recently shown the long- term efficacy of ICD therapy at aborting sudden death in the high-risk patient population. Although still evolving, general guidelines and indications for ICD implant have been put forth and are discussed in this review. From the first defibrillation in humans during surgery in 1947 to the sophisticated dual-chamber pacing and memory functions of the modern device, ICD development has led to ever smaller devices with more complex technol ogy. The implant procedure of current ICDs parallels that used to place pacemakers. However, the anesthe sia team plays a vital role in initial ICD implantation by monitoring cardiopulmonary status during defibrilla tion threshold (DFT) testing. Additionally, long-term management of ICDs often requires repeat DFT testing with anesthesia involvement. Finally, possible electro magnetic (environmental) interactions with the ICD of which physicians should be aware are described in this article.

The effect of psychological intervention on patients' long-term adjustment to the ICD: a prospective study

This study prospectively examined the role of cognitive behavioral therapy (CBT) in (1) alleviating psychological and somatic distress, and (2) lowering arrhythmic events requiring shocks. Forty-nine of 61 consecutive patients were randomized into therapy (CBT, n = 25) or no therapy (NT, n = 24) and completed a battery of self-report questionnaires at baseline and at 9-month follow-up. CBT was administered at preimplant, predischarge, and at seven routine follow-up visits. Patients were 65 +/- 10 years old, 65% were men, and 92% Caucasian. Eighteen (72%) CBT patients and 18 (75%) NT patients were retained at follow-up. Compared to CBT patients, NT patients reported higher levels of depression (P = 0.046), more anxiety (P = 0.013), more psychological distress (P = 0.015), poorer overall adjustment (P = 0.009), and poorer sexual functioning (P = 0.003). Mean number of shocks did not differ between the CBT and NT groups (2.85 vs 2.30, respectively); however, more patients in the CBT group (61%) than the NT group (33%) received shocks (P = 0.070). At follow-up, a subgroup analysis revealed that the significant differences observed between the CBT and NT groups were attributable to the patients who received shocks in both groups. In conclusion, CBT was associated with decreased depression, decreased anxiety, and increased adjustment for ICD recipients, particularly among those patients receiving shocks. CBT can be administered effectively at routine follow-up visits or transtelephonically with little added inconvenience to the ICD recipient.