Health-related quality-of-life assessment of patients with life-threatening ventricular arrhythmias

The Effect of Shock Burden on Heart Failure and Mortality

Background

Prior studies have demonstrated an association between appropriate implantable cardioverter defibrillator (ICD) shocks and mortality in clinical trials. The effect of shock burden on heart failure and mortality has not been previously studied in a large population-based cohort.

Methods

The cohort was derived using a comprehensive prospective ICD registry in the province of Nova Scotia with a mean follow-up of 4 ± 2.3 years. With the use of time-varying analysis, the relationship among shock burden, mortality, and heart failure hospitalization was determined.

Results

A total of 776 patients (mean age of 64.8 years) were included in the study, of whom 37% received appropriate therapy during follow-up. A single ICD shock did not confer an increased mortality risk compared with no therapy (hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.84-1.79; P = 0.3), but mortality risk was significantly increased with ≥ 2 shocks (HR, 3.23; 95% CI, 2.04-5.09; P < 0.0001). There was a significant increase in heart failure hospitalization associated with receiving 1 ICD shock (HR, 2.05; 95% CI, 1.46-2.89; P < 0.0001) or more than 1 ICD shock (HR, 4.36; CI, 2.53-7.52; P < 0.0001) compared with patients receiving no ICD therapy. Patients who received antitachycardia pacing alone showed no difference in heart failure hospitalization (HR, 0.93; CI, 0.67-1.29; P = 0.7) and improved survival (HR, 0.69; CI, 0.5-0.96; P = 0.03) compared with those receiving no ICD therapy.

Conclusion

Ventricular arrhythmia treated with appropriate ICD shocks is associated with an increased risk of heart failure hospitalization, whereas recurrent episodes of ventricular arrhythmia requiring shocks are associated with both higher mortality and higher heart failure hospitalization rates.

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.

Ventricular Tachycardia with ICD Shocks: When to Medicate and When to Ablate

PURPOSE OF REVIEW

Ventricular tachycardia occurrence in implantable cardioverter defibrillator (ICD) patients may result in shock delivery and is associated with increased morbidity and mortality. In addition, shocks may have deleterious mechanical and psychological effects. Prevention of ventricular tachycardia (VT) recurrence with the use of antiarrhythmic drugs or catheter ablation may be warranted. Antiarrhythmic drugs are limited by incomplete efficacy and an unfavorable adverse effect profile. Catheter ablation can be effective but acute complications and long-term VT recurrence risk necessitating repeat ablation should be recognized. A shared clinical decision process accounting for patients' cardiac status, comorbidities, and goals of care is often required.

RECENT FINDINGS

There are four published randomized trials of catheter ablation for sustained monomorphic VT (SMVT) in the setting of ischemic heart disease; there are no randomized studies for non-ischemic ventricular substrates. The most recent trial is the VANISH trial which randomly allocated patients with ICD, prior infarction, and SMVT despite first-line antiarrhythmic drug therapy to catheter ablation or more aggressive antiarrhythmic drug therapy. During 28 months of follow-up, catheter ablation resulted in a 28% relative risk reduction in the composite endpoint of death, VT storm, and appropriate ICD shock (p = 0.04). In a subgroup analysis, patients having VT despite amiodarone had better outcomes with ablation as compared to increasing amiodarone dose or adding mexiletine. There is evidence for the effectiveness of both catheter ablation and antiarrhythmic drug therapy for patients with myocardial infarction, an implantable defibrillator, and VT. If sotalol is ineffective in suppressing VT, either catheter ablation or initiation of amiodarone is a reasonable option. If VT occurs despite amiodarone therapy, there is evidence that catheter ablation is superior to administration of more aggressive antiarrhythmic drug therapy. Early catheter ablation may be appropriate in some clinical situations such as patients presenting with relatively slow VT below ICD detection, electrical storms, hemodynamically stable VT, or in very selected patients with left ventricular assist devices. The optimal first-line suppressive therapy for VT, after ICD implantation and appropriate programming, remains to be determined. Thus far, there has not been a randomized controlled trial to compare catheter ablation to antiarrhythmic drug therapy as a first-line treatment; the VANISH-2 study has been initiated as a pilot to examine this question.

Implantable Cardioverter Defibrillator Therapy and the Need for Concomitant Antiarrhythmic Drugs

Implantable cardioverter defibrillators (ICDs) are increasingly used for the prevention of sudden cardiac death in patients with life-threatening ventricular arrhythmias (VAs); however, there is a potential for severe and debilitating anxiety caused by symptoms associated with ICD therapy and anticipation of shocks. Anxiety is a psycho-logic stressor, including physiologic components that may lead to adrenergic excitation triggering new arrhythmias and ICD therapies. This often requires concomitant antiarrhythmic medication to reduce the frequency of shocks and symptomatic arrhythmias treated by anti-tachycardia pacing. Although published studies have documented the efficacy of currently available antiarrhythmics, they have limitations in patients with heart failure, may affect the defibrillation threshold, and/or have been associated with major side-effects. In conclusion, for the patient with an ICD experiencing symptomatic ventricular tachycardia (VTs) episodes or ICD shocks, there is a need for pharmacologic therapy to reduce the incidence of such events without affecting the performance of the ICD or causing major side-effects.

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

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

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

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

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

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

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

Depression, psychological distress, and quality of life in patients with cardioverter defibrillator with or without cardiac resynchronization therapy

Congestive heart failure is frequent and leads to reduced exercise capacity, reduced quality of life (QoL), and depression in many patients. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillators (ICD) offer therapeutic options and may have an impact on QoL and depression. This study was performed to evaluate physical and mental health in patients undergoing ICD or combined CRT/ICD-implantation (CRT-D). Echocardiography, spiroergometry, and psychometric questionnaires [Beck Depression Inventory, General World Health Organization Five Well-being Index (WHO-5), Brief Symptom Inventory and 36-item Short Form (SF-36)] were obtained in 39 patients (ICD: 17, CRT-D: 22) at baseline and 6-month follow-up (FU) after device implantation. CRT-D patients had a higher NYHA class and broader left bundle branch block than ICD patients at baseline. At FU, ejection fraction (EF), peak oxygen uptake, and NYHA class improved significantly in CRT-D patients but remained unchanged in ICD patients. Patients with CRT-D implantation showed higher levels of depressive symptoms, psychological distress, and impairment in QoL at baseline and FU compared to ICD patients. These impairments remained mostly unchanged in all patients after 6 months. Overall, these findings imply that there is a need for careful assessment and treatment of psychological distress and depression in ICD and CRT-D patients in the course of device implantation as psychological burden seems to persist irrespective of physical improvement.

Sleep quality and sleepiness in persons with implantable cardioverter defibrillators: outcome from a clinical randomized longitudinal trial

BACKGROUND

Patients receiving an implantable cardioverter defibrillator (ICD) report various types and degree of sleep disruptions, but little is known regarding their characteristics, duration, and associated factors. The purposes of this study were: (1) to describe the effect of a psychoeducational intervention on sleep quality and daytime sleepiness, (2) to describe patterns of sleep over time, and (3) to identify predictors of poor sleep in an ICD population.

METHODS

A randomized longitudinal intervention trial was designed to test the effects of a psychoeducational intervention, which included a sleep education and counseling session in patients receiving their initial ICD. Patients (n=236; 75% men; mean age 58.4 [±11.2] from the PsychoEducationAl Intervention for ICD PatiEnts (PEACE) trial comprised the study population. Variables related to sleep were measured by the Pittsburgh Sleep Quality Inventory (PSQI) and Epworth Sleepiness Scale (ESS).

RESULTS

No psychoeducational intervention effects on sleep outcomes were observed. However, 67.2% of the patients reported poor sleep quality at baseline, and 56.8% had low sleep quality at 6 months based on PSQI scores>5; one-third (32.6%) were excessively sleepy based on ESS scores≥10 at 6 months. Anxiety, depression, physical function, pain intensity, and pain severity were all highly correlated to each other across time. Female gender was a significant covariate for the PSQI. New York Heart Association (NYHA) class was a significant covariate for sleepiness (Epworth).

CONCLUSIONS

Low sleep quality and daytime sleepiness are found at time of insertion and over time in patients with ICD. Female gender, higher NYHA class, as well as two latent factors encompassing increased anxiety, depressive symptoms, and decreased physical function and increased pain, were significant predictors of poor sleep quality and sleepiness over time. These data help identify those at higher risk for sleep problems after ICD.

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.

Costs and quality-of-life effects of implantable cardioverter-defibrillators

Although the clinical efficacy of implantable cardioverter-defibrillators (ICDs) has been convincingly demonstrated in clinical trials, the impact of ICDs on health care costs and recipients' quality of life (QOL) is less certain. The existing medical research on the health care costs and QOL effects of ICDs was reviewed and summarized. Medline and the Institute for Scientific Information's Web of Knowledge were searched for publications reporting costs of care and QOL assessments of ICD recipients. Unpublished and non-peer-reviewed "gray" publications were excluded. Reports were included if they reported primary, original patient data that were collected after 1993, when nonthoracotomy defibrillators entered clinical practice. Two reviewers independently evaluated publications for relevance and quality, abstracted study data, and summarized the findings. Excessive heterogeneity among studies prevented formal meta-analysis, so a narrative synthesis was performed, and key themes were identified from the published research. There were limited published data on the costs of ICD care, especially for the primary prevention of sudden cardiac death. The published research on ICD QOL lacked large, multicenter, longitudinal studies. Many ICD QOL studies were performed in small numbers of patients at single centers. Initial ICD implantation costs ranged (in 2006 United States dollars) from $28,500 to $55,200, with annual follow-up costs ranging from $4,800 to $17,000. QOL was higher for ICD recipients than for patients treated with antiarrhythmic drugs, but there was a substantial prevalence of anxiety, depression, and "loss of control" in ICD recipients, particularly in those who had received ICD shocks. In conclusion, ICD implantation remains costly but may be becoming less expensive over time, and ICD recipients' QOL is significantly affected by their devices.

The Role of the Psychologist in Adult Congenital Heart Disease

In addition to monitoring and treating the cardiac disease, patients benefit from health professionals recognizing and managing the potential psychosocial consequences of growing up with congenital heart disease. Working groups from Europe and North America have emphasized the benefit of inclusion of specialized mental health care for adult congenital heart disease (ACHD) patients. This article reviews the evidence that ACHD patients have special and unique psychosocial needs and outlines ways in which psychologists can be integrated into multidisciplinary ACHD care teams. There are three professional domains in which clinical health psychologists can contribute to an ACHD team: provision of clinical services, multidisciplinary research, and professional education. Considerations for incorporating psychology into ACHD teams are presented.

Psychological indices and phantom shocks in patients with ICD

INTRODUCTION

Some patients with ICDs experience the sensation of a shock in the absence of true therapy (phantom shock). We hypothesize that phantom shocks may be a manifestation of anxiety, depression or PTSD.

METHODS AND RESULTS

All patients over 18 years old with an ICD were eligible to enroll in the study. The first 75 subjects who agreed to participate were enrolled and divided into three groups: ICD patients with phantom shocks (n = 19); ICD patients who had actual shocks (n = 28) and ICD patients who had no shocks (n = 28). During a clinic visit a demographic questionnaire and three psychological rating scales were administered: the Spielberger State-Trait Anxiety Inventory (STAI); the Center for Epidemiologic Studies Depression Scale (CES-D) and the Posttraumatic Stress Checklist (PCL-C). No significant differences between groups were found in gender, race, age, history of MI or cardiac surgery status. Data analysis of the psychological indices using one-way ANOVA showed that the group with phantom shocks had more depression (CES-D p = 0.011) and more anxiety (STAI p = 0.010) than the other groups. Multiple comparisons of group means showed a greater percentage of clinically depressed patients in the phantom shock group than in the other groups.

CONCLUSION

Patients with phantom shocks are more likely to be clinically depressed and have higher levels of anxiety than other ICD patients, regardless of history of actual shocks.

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 Death: Implantable Cardioverter Defibrillators and Proactive Care

OBJECTIVES

The purpose of this paper is to discuss quality of death (QOD) among patients with congestive heart failure (CHF) and implantable cardioverter defibrillators. We outline recommendations that enhance QOD from the device patient and specialty cardiology perspectives.

BACKGROUND

Contemporary treatment of CHF patients routinely includes both pharmacologic therapy and the use of cardiac devices. The implantable cardioverter defibrillator prevents premature death in heart failure patients, though not death itself.

CONCLUSIONS

Active discussion and consideration of patient's QOD is indicated in implantable cardioverter defibrillator patients to prevent unnecessary treatment and to increase control over perceived quality of life by patients and family.

Predictors of quality of life in patients with implantable cardioverter defibrillators

Few studies have prospectively examined characteristics of implantable cardioverter defibrillator (ICD) patients as predictors of postimplant outcome. In this study the authors considered the association between preimplant psychological characteristics, ICD shocks, and postimplant quality of life at short- and long-term follow-ups, controlling for age and ejection fraction (N=88). Hierarchical regression analyses revealed that history of depression, trait anxiety, optimism, social support, and ICD shocks accounted for 41.8% to 64.5% of the variance in quality of life indices at 8- and 14-month follow-ups, depending on the outcome assessed. Further, psychological variables were as strong as, or stronger than, age, ejection fraction, and ICD shocks in predicting quality of life outcomes.

Internal defibrillation with minimal skeletal muscle activation: A new paradigm toward painless defibrillation

BACKGROUND

Shock-induced pain produces substantial morbidity in recipients of implantable cardioverter-defibrillators (ICDs). This pain likely derives from activation of skeletal muscle and associated nerves in the chest and abdomen. In an effort to develop a painless defibrillation system, we designed an electrode arrangement that incorporates a conductive sock placed around the heart to confine the electric shock field to cardiac tissue.

OBJECTIVES

The purpose of this study was to test whether cardiac defibrillation could be achieved without skeletal muscle activation using a novel electrode system.

METHODS

Eight adult mongrel dogs were studied. Force of skeletal muscle contraction was measured by strain gauges attached to the forelimbs during delivery of internal shocks ranging in energy from 0.1 to 31 J. Biphasic shocks were delivered (1) between a right ventricular coil and a subcutaneous dummy can (standard configuration), and (2) between a left ventricular coil and an epicardial electrode sock. Internal and external defibrillation thresholds (DFTs) were determined for each electrode configuration.

RESULTS

Shock-induced muscle contraction force was significantly lower using the sock electrode than with standard ICD electrodes at every shock energy level tested (P < .0001). Internal DFT was similar between electrode configurations (sock electrode: 8.6 +/- 4.2 J; standard: 11.0 +/- 6.3 J, P = .4), but muscle contraction force at DFT was greatly reduced with the new electrode system (1.8 +/- 2.0 kg vs 10.6 +/- 2.1 kg, P < .0001). The sock electrode rendered external defibrillation impossible, however, even at 360 J.

CONCLUSION

Skeletal muscle activation induced by ICD shocks can be greatly reduced using an electrode system that confines the electric shock field to the heart. Refinement of this strategy may allow for delivery of painless shocks by ICDs. Further development is needed to overcome implant complexity and the higher external DFT with this type of electrode system.

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.

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.

Implantable cardioverter-defibrillators, induced anxiety, and quality of life

Since its approval in 1985, the implantable cardioverter-defibrillator (ICD) has supplanted antiarrhythmic drugs as the standard of care for patients with potentially lethal ventricular arrhythmias. The increased popularity of ICDs stems primarily from their safety and tolerability compared with commonly used medications notorious for adverse drug reactions. As ICD indications have broadened, the number of implantations has increased substantially, and more attention has been directed to sequelae of implantation, particularly after ICD firing. Although scant, studies of quality of life and psychiatric symptoms in patients with ICDs consistently report assorted psychiatric disturbances affecting up to 87% of recipients. Depression and anxiety predominate: up to 38% of patients experience symptoms that meet diagnostic criteria for an anxiety disorder. Psychological theories such as the classic conditioning model, learned helplessness model, and cognitive appraisal model have been invoked to conceptualize these new-onset ICD-induced anxiety disorders. Small trials of psychosocial interventions, including support groups and cognitive behavioral therapy, have had mixed results. Little is known about preexisting anxiety disorders in ICD recipients, particularly which premorbid features predict a worse prognosis, other than suggestions that younger patients and those receiving multiple shocks are at greater risk. Prospective studies of the psychopathology of patients with ICDs, both before and after implantation, are warranted.

The effects of age on quality of life in implantable cardioverter defibrillator recipients

BACKGROUND

The implantable cardioverter defibrillator shows superiority over conventional pharmacological therapy. The implantable cardioverter defibrillator has been implanted with increasing frequency in patients who are either at risk for or have experienced a life-threatening dysrhythmia. Implantable cardioverter defibrillator recipients experience a myriad of physical, emotional and social adjustments, with little being known about the impact of age on trajectory. AIMS, OBJECTIVES AND DESIGN: Therefore the purpose of the study is to examine the effects of age on health status, quality of life, and mood states of implantable cardioverter defibrillator recipients during the first year after implantation using a repeated measures design.

METHODS

A comparison of implantable cardioverter defibrillator patients' scores with other samples, both ill and well, are discussed to see how the two implantable cardioverter defibrillator age groups compare on the various measures. Human subjects approval was obtained from the institutional review board.

RESULTS

Seventy subjects, 51 males and 19 females, were recruited. There were 31 subjects between the ages of 21 and 62 years, mean age of 51 years, that comprised the younger age group, and 39 subjects between the ages of 67 and 84 years, mean age of 74 years, that comprised the older age group. Each subject completed the Medical Outcomes SF-36, the Ferrans and Powers Quality of Life Index, and the Profile of Moods States at time of implantable cardioverter defibrillator implantation, and 6 and 12 months later.

CONCLUSIONS

The older age group was as expected less physically active, less satisfied with their physical functioning, and had slightly more anxiety at 6 and 12 months than the younger counterparts. The younger implantable cardioverter defibrillator recipients demonstrated some improvements over time in the perception of their physical adjustment and anxiety.

RELEVANCE TO CLINICAL PRACTICE

Comparison of the SF-36 with other populations with or without a medical condition revealed scores below norms in physical health for both groups, and only slightly higher than patients with heart failure for the older group.

Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation

BACKGROUND

Mortality after out-of-hospital cardiac arrest from ventricular fibrillation is high. Programs focusing on early defibrillation have improved the rate of survival to hospital discharge. We conducted a population-based analysis of the long-term outcome and quality of life of survivors.

METHODS

All patients who had an out-of-hospital cardiac arrest between November 1990 and January 2001 who received early defibrillation for ventricular fibrillation in Olmsted County, Minnesota, were included. The survival rate was compared with that of an age-, sex-, and disease-matched (2:1) control population of residents who had not had an out-of-hospital cardiac arrest and with that of age- and sex-matched controls from the general U.S. population. The quality of life was assessed with use of the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and compared with U.S. population norms.

RESULTS

Of 200 patients who presented with an out-of-hospital cardiac arrest with ventricular fibrillation, 145 (72 percent) survived to hospital admission (7 died in the emergency department) and 79 (40 percent) were neurologically intact (good overall capability or moderate overall disability) at discharge. The mean (+/-SD) length of follow-up was 4.8+/-3.0 years. Nineteen patients died after discharge from the hospital. The expected five-year survival rate (79 percent) was identical to that among age-, sex-, and disease-matched controls (P=0.68) but lower than that among the age- and sex-matched U.S. population (86 percent, P=0.02). Fifty patients completed SF-36 surveys at the end of follow-up, and the majority had a nearly normal quality of life, with the exception of reduced vitality.

CONCLUSIONS

Long-term survival among patients who have undergone rapid defibrillation after out-of-hospital cardiac arrest is similar to that among age-, sex-, and disease-matched patients who did not have out-of-hospital cardiac arrest. The quality of life among the majority of survivors is similar to that of the general population.

Life after a ventricular arrhythmia

BACKGROUND

There are few data from community-based evaluations of outcomes after a life-threatening ventricular arrhythmia (LTVA). We evaluated patients' quality of life (QOL) and medical costs after hospitalization and treatment for their first episode of an LTVA.

METHODS

We prospectively evaluated QOL by use of the Duke Activity Status Index (DASI), Medical Outcomes Study SF-36 mental health and vitality scales, the Cardiac Arrhythmia Suppression Trial (CAST) symptom scale, and resource use in patients discharged after a first episode of an LTVA in a managed care population of 2.4 million members.

RESULTS

We enrolled 264 subjects with new cases of LTVA. Although functional status initially decreased compared with self-reports of pre-event functional status, both functional status and symptom levels improved significantly during the study period. These improvements were greater in patients receiving an implantable cardioverter defibrillator (ICD) than in patients receiving amiodarone. Ratings of mental health and vitality were not significantly different between the treatment groups and did not change significantly during follow-up. The total 2-year medical costs were higher for patients receiving an ICD than for patients receiving amiodarone, despite lower costs during the follow-up period for the patients receiving an ICD.

CONCLUSIONS

New onset of an LTVA has a substantial negative initial impact on QOL. With therapy, most patients have improvements in their QOL and symptom level, possibly more so after treatment with an ICD. The costs of treating these patients are very high.

The prevention of sudden death in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a familial myocardial disease caused by mutations in cardiac sarcomeric proteins. HCM is characterised by myocyte disarray and myocardial fibrosis. Most patients are largely asymptomatic but some are prone to a number of disease-related complications, the most problematic of which is sudden cardiac death. Diagnosing patients who are at risk has not been easy because of the clinical heterogeneity of the disease, the frequent absence of symptoms prior to sudden cardiac death and the relatively low disease prevalence and annual mortality rates. To date, both low-dose amiodarone and internal cardioverter/defibrillator implantation have been advocated in high-risk individuals. Further improvements in clinical understanding and risk stratification are necessary to identify HCM patients who are at high risk of sudden death.

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.

The role of pharmacologic treatment to prevent sudden death in the implantable cardioverter defibrillator era

The prevention of sudden death remains a key aspect of clinical management in patients with hypertrophic cardiomyopathy (HCM). For many years, amiodarone has been widely used to treat and prevent symptomatic atrial arrhythmias in patients with HCM, but its role in the prevention of potentially fatal ventricular arrhythmia has remained controversial. The publication of several observational studies examining the efficacy of implantable cardioverter defibrillators (ICDs) in patients with the disease has stimulated a re-evaluation of the drug's place in the management of HCM. This article reviews the literature on amiodarone therapy in HCM and discusses the indications for its use in the ICD era.

Could implantable cardioverter defibrillators provide a human model supporting the learned helplessness theory of depression?

Affective symptoms were examined retrospectively in 25 patients following placement of implantable cardioverter defibrillators (ICD) which can produce intermittent shocks without warning in response to cardiac ventricular arrhythmias. The number of ICD random, uncontrollable discharge shocks and pre-ICD history of psychological distress (i.e., depression and/or anxiety) were documented in all patients using a demographics questionnaire and a standardized behavioral/psychological symptoms questionnaire (i.e., Symptom Checklist-90 Revised). ICD patients were dichotomized into two groups: those without a history of psychological distress prior to ICD (n = 18) and those with a history of psychological distress prior to ICD (n = 7). In ICD patients without a prior history, results indicated that quantity of ICD discharge shocks was significantly predictive of current reported depression (r = 0.45, p = 0.03) and current reported anxiety (r = 0.51, p = 0.02). Conversely, in patients with a reported history of psychological distress, there was no significant relationship found between quantity of discharge shocks and current reported depression or anxiety. This study may provide evidence in support of a human model of learned helplessness in that it supports the notion that exposure to an unavoidable and inescapable aversive stimulus was found to be related to patients' reported depression. Further studies may wish to prospectively consider a larger sample as well as a more comprehensive assessment of premorbid psychological symptoms.