Florid psychopathology in patients receiving shocks from implanted cardioverter-defibrillators

Long-term evaluation of sensing variability of a floating atrial dipole in a single‑lead defibrillator: The mechanistic basis of long-term stability of amplified atrial electrogram

BACKGROUND

A single‑lead implantable cardioverter-defibrillator (ICD) with a floating atrial dipole has been developed to enhance the diagnostic capability of atrial arrhythmias and to facilitate adjudication of arrhythmic events without the additional effort required for atrial lead insertion. However, there have been concerns about the long-term reliability of atrial sensing.

METHODS

We enrolled patients with the single-chamber ICD with atrial-sensing electrodes from 4 tertiary university hospitals in Korea. Minimal, maximal, and mean P wave amplitudes were collected at 3-6 months, 6-12 months, and 12-24 months after implantation. The difference between the minimal and maximal sensing amplitudes was calculated as an indicator of the variability of atrial sensing, while the atrial sensing stability was assessed using the mean amplitude.

RESULTS

A total of 86 patients were included for analysis. The variability of atrial sensing amplitudes significantly decreased at 12-24 months compared to 3-6 months (p = 0.01), while mean atrial amplitudes were stable throughout the mean follow-up duration of 17.4 months. Nine patients (10.5%) experienced inappropriate ICD therapy mostly due to misclassification of supraventricular tachycardia.

CONCLUSIONS

Under the hypothesis that sensing stability can be guaranteed as the variability decreases with time, we suggest that the concern about long-term sensing stability of a floating dipole can be abated with an ICD that has been implanted for over 2 years.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevention of Recurrent Ventricular Tachycardia in Patients With Implantable Cardioverter Defibrillators-A Network Meta-analysis

BACKGROUND

The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile.

STUDY QUESTION

Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs?

DATA SOURCES

Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library.

STUDY DESIGN

Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model.

RESULTS

Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11-0.74] and 0.15 (95% CI, 0.04-0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20-0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22-0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92-6.26).

CONCLUSIONS

Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.

A successful catheter ablation of a ventricular fibrillation

Malignant ventricular arrhythmias are challenging to manage, requiring a multidisciplinary approach. The mechanism, which triggers ventricular fibrillation (VF) associated with ventricular extrasystoles has not been clarified yet, however, abolishing ventricular extrasystoles may stop ventricular fibrillation in these patients. By this case presentation, we aimed to present a successful treatment of an electrical storm (ES), which developed after an acute myocardial infarction, by catheter ablation.

Comparison of Inappropriate Shocks and Other Health Outcomes Between Single- and Dual-Chamber Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death: Results From the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter-Defibrillators

BACKGROUND

In US clinical practice, many patients who undergo placement of an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden cardiac death receive dual-chamber devices. The superiority of dual-chamber over single-chamber devices in reducing the risk of inappropriate ICD shocks in clinical practice has not been established. The objective of this study was to compare risk of adverse outcomes, including inappropriate shocks, between single- and dual-chamber ICDs for primary prevention.

METHODS AND RESULTS

We identified patients receiving a single- or dual-chamber ICD for primary prevention who did not have an indication for pacing from 15 hospitals within 7 integrated health delivery systems in the Longitudinal Study of Implantable Cardioverter-Defibrillators from 2006 to 2009. The primary outcome was time to first inappropriate shock. ICD shocks were adjudicated for appropriateness. Other outcomes included all-cause hospitalization, heart failure hospitalization, and death. Patient, clinician, and hospital-level factors were accounted for using propensity score weighting methods. Among 1042 patients without pacing indications, 54.0% (n=563) received a single-chamber device and 46.0% (n=479) received a dual-chamber device. In a propensity-weighted analysis, device type was not significantly associated with inappropriate shock (hazard ratio, 0.91; 95% confidence interval, 0.59-1.38 [P=0.65]), all-cause hospitalization (hazard ratio, 1.03; 95% confidence interval, 0.87-1.21 [P=0.76]), heart failure hospitalization (hazard ratio, 0.93; 95% confidence interval, 0.72-1.21 [P=0.59]), or death (hazard ratio, 1.19; 95% confidence interval, 0.93-1.53 [P=0.17]).

CONCLUSIONS

Among patients who received an ICD for primary prevention without indications for pacing, dual-chamber devices were not associated with lower risk of inappropriate shock or differences in hospitalization or death compared with single-chamber devices. This study does not justify the use of dual-chamber devices to minimize inappropriate shocks.

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.

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.

Fearful Appraisals and Behavioral Responses of a Patient with an Implantable Cardioverter Defibrillator

The implantable cardioverter defibrillator (ICD) is an effective treatment device for potentially malignant arrhythmias, including those leading to sudden cardiac death. However, some patients develop a variety of adjustment problems to the ICD. Clinical behavioral scientists have conceptualized ICD adjustment problems using principles of classical conditioning (i.e., cardiophobia), the learned helplessness paradigm of depression, and cognitive-behavioral models of panic. This case study likens ICD adjustment problems to a cognitive-behavioral model of panic and chest pain illustrating the limits of thesemodels in terms of howType I/Type II threat appraisal by the patient serves as a significant barrier to full symptomresolution. This case study supports the need formodifications in suchmodels and related interventions as they relate to the presence of real comorbid risk factors.

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.

Advances in implantable cardioverter defibrillator therapy

Since the first implant in 1980, implantable cardioverter defibrillator (ICD) technology has progressed rapidly. Modern ICD's have hundreds of programmable options with the general goal of preventing inappropriate shocks and providing shocks for truly life threatening symptomatic ventricular arrhythmias. New studies on ICD programming have shown the benefits of prolonged detection intervals in reaching this goal. Anti-tachycardia pacing (ATP) therapy has become an important adjunct to defibrillator shocks. Remote monitoring technologies have surfaced which have been shown to identify arrhythmias and problems with the device in an expedient fashion. The subcutaneous ICD offers the advantage of avoiding intravascular leads and their inherent risks. Lastly, the current understanding of the effects of MRI in ICD patients has advanced creating new opportunities to provide MRI safely to such patients.

Programming implantable cardioverter/defibrillators and outcomes

Implantable cardioverter-defibrillators are complex technical devices with a multitude of programming options for the physician. In recent years, numerous randomized trials have been performed to define the optimal programming strategies and have provided valuable insights, especially in primary prevention patients. This article provides an actual overview on the existing evidence on the most important programming features for accurate detection and therapy of ventricular arrhythmias.

Implantable cardioverter-defibrillator shock prevention does not reduce mortality: a systemic review

BACKGROUND

Mortality is increased among implantable cardioverter-defibrillator (ICD) recipients who receive shocks; however, whether shocks cause this increase or are simply a marker of risk is unknown. Antiarrhythmic medications, catheter ablation, and enhanced ICD programming all may reduce ICD shocks, but whether shock reduction decreases mortality is unknown.

OBJECTIVE

The purpose of this study was to conduct a meta-analysis to estimate the impact of ICD shock reduction on survival.

METHODS

Two independent reviewers searched MEDLINE, EMBASE, and clinicaltrials.gov and extracted data from randomized controlled trials assessing the efficacy of interventions to prevent ICD shocks.

RESULTS

Seventeen randomized trials were included in this analysis, including 5875 patients. Mean ejection fraction of all trial participants was 32%, and 25% of the patients received ICD therapy for primary prophylaxis. Antiarrhythmic medications (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.36-0.96, P = .03) and catheter ablation of ventricular tachycardia (OR 0.35, 95% CI 0.19-0.62, P = .0004) significantly reduced the proportion of patients receiving shocks. However, there was no significant reduction in mortality among trials of antiarrhythmic medications (OR 1.07, 95% CI 0.72-1.59, P = .73) or catheter ablation (OR 0.72, 95% CI 0.32-1.64, P = .44). The 5 ICD programming trials had sufficiently heterogeneous interventions that pooling of their results was not performed. However, only the PAINFREE-II (Pacing Fast Ventricular Tachycardia Reduces Shock Therapies) trial demonstrated a significant reduction in shocks (OR 0.38, 95% CI 0.22-0.65), but this was not associated with any significant reduction in mortality (OR 1.41, 95% CI 0.81-2.45).

CONCLUSION

There is no compelling evidence that existing interventions that reduce ICD shocks significantly improve survival.

Exercise training and cardiac rehabilitation in patients with implantable cardioverter defibrillators: a review of current literature focusing on safety, effects of exercise training, and the psychological impact of programme participation

BACKGROUND

Indications for implantable cardioverter defibrillators (ICDs) have been widened considerably during the last decade due to the well-documented effect in the heart failure population. Exercise training (ET) has a 1A recommendation in heart failure. However, data on safety and efficacy of ET in patients with ICDs is sparse. ICD shocks are associated with reduced quality of life and increased mortality. Whether ET may have a beneficial effect in heart failure patients with an ICD is not well documented.

METHODS

This review is based on a systematic search in the Pub Med database using the terms 'exercise training', 'implantable cardioverter defibrillator', and 'cardiac rehabilitation'.

RESULTS

Nine studies were identified, comprising 1889 patients. The average duration of exercise-based cardiac rehabilitation (CR) was 9.6 weeks. Ten ICD therapies (seven shocks) were reported in the 834 patients with ICD during ET. Between exercise sessions and during follow up 182 events were recorded including 166 shocks. Three studies (2 randomized) showed that the control group representing sedentary patients were more prone to ICD discharge than patients undergoing CR/ET. In all studies the ICD patients improved their aerobic fitness following ET. Few studies report data on the effect of ET on anxiety and depression.

CONCLUSION

Based on the current literature, ET in patients with an ICD seems to be safe and is not associated with increased risk of shocks. ET improves aerobic capacity in ICD patients, while effects on anxiety, depression and quality of life are still under debate.

Psychopathology in postinfarction patients implanted with cardioverter-defibrillators for secondary prevention. A cross-sectional, case-controlled study

OBJECTIVE

To determine (1) the incidence of anxiety and depression in patients implanted with defibrillators for secondary arrhythmia protection after myocardial infarction; (2) the effect of comorbidity and receipt of shock therapy on psychosocial maladjustment.

METHODS

Cross-sectional, one-off, questionnaire-based (HADS; MOS SF-36), case-controlled study of defibrillator recipients (n=100) from a 3-year implant period and three groups of matched controls [pacemaker (n=50), coronary intervention (n=50), atrial fibrillation (n=50)], sharing specific preselected previous health experiences. Spouses of each subgroup (n=106) were also studied. Although a cardiac rehabilitation program was available routinely for postinfarction patients, no specific rehabilitation was provided after defibrillator or pacemaker implant.

RESULTS

Mean scores for each assessment were similar for each group. Individual patient scores, however, revealed similarly high incidences of anxiety (24-34%) and depression (14-22%) in all groups. Experience of implantable cardioverter-defibrillator (ICD) 'shock(s)' and 'shock storm(s)' (≥ 3 shocks in 24 h) increased anxiety significantly. HADS criteria for anxiety 'caseness' or borderline 'caseness' were met in 63.6% of shock-storm recipients. Abnormal anxiety scores did not differ with interval from index event. Individual HADS scores also identified high incidences of anxiety in all spouse groups (25-48%).

CONCLUSIONS

Experience of shock storm precipitates pathological levels of anxiety in ICD recipients, and need for an ICD contributes to spouse anxiety. Individual CBT is indicated for patients who experience multiple shocks along with psycho-education for spouses. Anxiolytic and antidepressant medications may be indicated as part of their psychological rehabilitation.

Effects of an alert system on implantable cardioverter defibrillator-related anxiety: rationale, design, and endpoints of the PANORAMIC multicentre trial

AIMS

Implantable cardioverter defibrillators (ICD) can prevent sudden cardiac death by delivering high-energy shocks in patients at risk of life-threatening ventricular tachyarrhythmias. Patients may be anxious about receiving inappropriate shocks in case of device or lead system malfunction, or about failing to receive needed therapy for the same reason. New devices include programmable vibrating patient notifiers (PN), which, by warning patients of a possible device dysfunction, might lower device-related anxiety. PAtient NOtifier feature for Reduction of Anxiety: a Multicentre ICD study (PANORAMIC) is a multicentre, randomized, clinical trial designed to examine the effects of the awareness of an active vibrating alert system on device-related anxiety.

METHODS

The trial will randomly assign 356 patients in a 1:1 design to a control group (PN OFF) vs. a treatment group (PN ON). Patients will be followed for 12 months, with visits scheduled at 6 and 12 months. During clinical follow-up visits, the ICD will be interrogated, and all patients will complete the Hospital Anxiety and Depression Scale and a device-related anxiety questionnaire. The sensitivity and specificity of PN, the effect of personality on anxiety, using the Type D scale (DS14), the number of delivered appropriate and inappropriate ICD therapies, changes in anxiety related to the delivery of appropriate or inappropriate shocks, crossovers from the assigned group, the number of hospitalizations, and the mortality rate will also be assessed. ClinicalTrials.gov Identifier: NCT00559559.

Long-term Effects of Implanted Cardioverter-Defibrillators on Health Status, Quality of Life, and Psychological State

Background Living with an implanted cardioverter-defibrillator increases survival, but the effects of the device on health status, quality of life, and psychological state over time are not clear.

Objectives To investigate changes in health status, quality of life, and psychological state associated with implantation of a cardioverter-defibrillator from implantation to 4 years later.

Methods A prospective, longitudinal design was used to measure changes in scores on the Short Form 36 of the Medical Outcomes Study, the Quality of Life Index–Cardiac III, and the Profile of Moods States short form at implantation, 6 months, and 1, 2, 3, and 4 years later.

Results A total of 30 men and 11 women (mean age, 60.4 years) completed all 4 years of follow-up. The physical and mental health composite summary scores of the Short Form 36 changed significantly over time; the mental health score improved (F = 2.95; P = .03), and the physical score worsened (F = 3.69; P = .003). Scores on the Quality of Life Index–Cardiac III did not change significantly. Negative moods were significantly fewer, and the total psychological distress score was significantly lower (F = 10.21; P < .001) during the 4 years of follow-up.

Conclusions Patients had improved mental health and reduced psychological distress by 6 months after implantation. Perception of physical health declined during the 4 years after implantation; the role physical subscore of the Short Form 36 indicated significant improvement in functioning at 6 months and a trend toward reduced functioning at 3 and 4 years after implantation.

An updated review of implantable cardioverter/defibrillators, induced anxiety, and quality of life

During the past 2 years the number of studies examining psychopathology and quality of life after ICD implantation has increased dramatically. Variables assessed have included recipient age, gender, and social support network. How recipients respond to having the device, particularly after experiencing firing, has been evaluated in light of new depression and anxiety disorder diagnoses as well as premorbid personality structure. Now the picture of what is known is, if anything, cloudier than it was 2 years ago, with little definitive and much contradictory data emerging in most of these categories. It still seems clear that in a significant minority of ICD recipients the device negatively affects quality of life, probably more so if it fires. Education about life with the device before receiving it remains paramount. Reports continue to appear of patients developing new-onset diagnosable anxiety disorders such as panic and posttraumatic stress disorder. Until recently the strongest predictors of induced psychopathology were considered to be the frequency and recency of device firing. It now seems that preimplantation psychologic variables such as degree of optimism or pessimism and an anxious personality style may confer an even greater risk than previously thought. Certainly many variables factor into the induction of psychopathology in these patients. Among these factors are age, gender, and perception of control of shocks, as well as the predictability of shocks and psychologic attributions made by the patient regarding the device. Another source of variability is this population's medical heterogeneity. Some patients receive ICDs after near-death experiences; others get them as anticipatory prophylaxis. Some have longstanding and entrenched heart disease; others were apparently healthy before sudden dangerous arrhythmias. Diagnoses as diverse as myocardial infarction in the context of advanced coronary artery disease and dilated cardiomyopathy after acute viral infection may warrant ICD placement. Moreover the course of cardiac disease after ICD placement may vary from relative stability to continuing disease progression and severe functional compromise. Unless these and other pre- and postimplantation differences are taken into account, it is almost impossible to make meaningful comparisons between studies. Ideally, future research would consist either of large-scale, randomized, prospective studies using validated structured-interview tools to supplement a literature dominated by self-report measures, unstructured assessments, and anecdotal reports, or of smaller studies designed to focus on particular diagnostic subsets. As ICDs become the standard of care for potentially life-threatening arrhythmias, the rate of implantations continues to increase. Because negative emotions have been linked to an increased incidence of arrhythmias, and untreated or unrecognized psychiatric illness can interfere with adaptation to an ICD, assessing and managing both pre-existing and induced psychiatric disorders becomes even more critical. Greater research attention should be paid to determining which patients meet criteria for anxiety disorders before and after implantation and what premorbid traits predispose to postimplantation psychopathology. The authors predict that psychiatrists will be involved increasingly in caring for this population, offering insights into treatment options that increase the likelihood of successful ICD acceptance and decrease the psychosocial costs of these devices.

Stability and cause of anxiety in patients with an implantable cardioverter-defibrillator: A longitudinal two-year follow-up

OBJECTIVE

Several investigations have found that anxiety disorders often develop in patients with an implantable cardioverter-defibrillator (ICD). This study investigated the inter--and intraindividual stability of anxiety and its relation to ICD activity in patients with an ICD.

METHODS

Changes in the psychopathology of 35 patients with an ICD were assessed at the beginning of the trial period and 2.5 years later. Psychometric measures of anxiety were collected. During this period, shocks and antitachycardia pacing were assessed.

RESULTS

Anxiety was found to be interindividually stable. We also found a slight, but statistically significant, reduction in trait anxiety and avoidance behavior over time. Patients who experienced shocks or antitachycardia pacing did not differ on psychometric or demographic variables from patients without those events.

CONCLUSIONS

Anxiety seems to be interindividually stable in patients with an ICD. We found no connection between anxiety and tachycardia episodes in patients with an ICD.

Depression and anxiety status of patients with implantable cardioverter defibrillator and precipitating factors

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are life-saving devices in treatment of life-threatening arrhythmia. We evaluate the emotional status of Turkish patients with ICD and try to explain factors that affect emotional status of the patients.

METHODS

Ninety-one patients with previously implanted ICD were included in the study. Follow-up periods, presence of ICD shock, shock frequency, time of the recent shock, age, and gender were noted. Depression and anxiety scores were evaluated according to Hospital Anxiety and Depression (HAD) chart.

RESULTS

Mean anxiety and depression scores were found as 9.1 +/- 5.3 and 7.2 +/- 5.1, respectively. According to HAD charts, 42 patients (46%) had anxiety and 37 patients (41%) had depression. Depression scores indicated significant difference between subgroups divided on the basis of follow-up periods (P = 0.026) and on the basis of time of recent shock (P = 0.028). There was significant difference in anxiety scores (P = 0.016) between patients with ICD shocks and patients with no shocks. When the patients were divided into subgroups according to shock frequency, both depression (P = 0.024) and anxiety (P = 0.016) scores presented significant difference. In female patients, depression and anxiety scores were found significantly higher compared to male patients (P = 0.046 and P = 0.016, respectively). In multivariate analysis, gender and shock frequency were found as predictors for anxiety scores (P = 0.019 and P = 0.044, respectively). However same analysis revealed no predictive factor for depression score.

CONCLUSION

Our study indicates presence of depression and anxiety in nearly half of the patients with ICD. Consultation with psychiatry should be a part of the treatment for patients with ICD, especially for those who constitute high-risk groups.

Psychological Distress in Patients with ICD Recall

BACKGROUND

Multiple clinical trials have shown that a properly functioning implantable cardioverter-defibrillator (ICD) is capable of interrupting sudden death caused by ventricular tachyarrhythmias. However, ICDs are complex medical devices, and they do not always perform as expected or they may fail completely. Exposure of ICD recipients to professional or media reports that their specific device type is potentially malfunctioning could negatively influence their psychological status.

METHODS

This study aimed to evaluate and quantify psychological distress in patients implanted with an ICD-recall device. Thirty patients implanted with ICD-recall devices (ICD-recall group) and 25 patients with unaffected ICD devices (ICD-control group) were interviewed using the Brief Symptom Inventory (a psychological self-report symptom scale).

RESULTS

Mean values of all primary psychiatric distress symptom dimensions and global indices were within the normal range for both the ICD-recall and the ICD-control group. New York Heart Association (NYHA)class was a predictor of higher distress symptoms in all categories, independently of the ICD group. NYHA II group patients tended toward higher stress levels than the NYHA I group, but only somatization was significantly different. An upward, but not significant, trend in 7 of the 12 scales was associated with symptomatic shock experience.

CONCLUSION

This study demonstrates that psychological distress was not significantly increased in patients recently informed about a potential malfunction of their device.

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.

A CNS-facilitated ICD support group: a clinical project evaluation

PURPOSE

The purpose of this article is to describe and evaluate a clinical nurse specialist (CNS)-facilitated support group for recipients of implantable cardioverter defibrillator. Specific evaluation aims were as follows: (1) How do demographic and clinical factors differ between those who attended the support group and those who did not? (2) Is there a difference in the quality of life index (QLI) of individuals with an implantable cardioverter defibrillator who attended the CNS-facilitated support group and those who did not? (3) What demographic and clinical factors are related to QLI?

DESIGN AND METHOD

Clinical project theory-based objectives were described. Implementation of the project was evaluated by retrospective survey of all implantable cardioverter defibrillator recipients during a 10-year time frame using the Ferrans and Powers' Quality of Life Index: Cardiac Version and demographic questionnaire. Attendance sheets defined who attended so comparisons could be made.

EVALUATION RESULTS

One hundred and twelve surveys were returned (34% return rate). A positive relationship between CNS visit during hospitalization, number of and value of supports, years of education, and ejection fraction was noted with attendance at the support group. No between-group differences on total QLI, or on any subscales, were found. Comorbidity was the only clinical factor correlated with QLI.

CONCLUSION

CNS-facilitated support groups can be offered as an additional support. Evaluation design issues limited the measuring outcomes of existing interventions. Future prospective studies are recommended to determine the affect of the support group on quality of life.

Fully automatic external defibrillators in acute care: Clinicians' experiences and perceptions

BACKGROUND

Fully automatic external defibrillators (FAEDs) reduce the time to defibrillation [Martinez-Rubio A, Kanaan N, Borggrefe M, Block M, Makijarvi M, Fedele F, et al. Advances in treating in-hospital cardiac arrest: safety and effectiveness of a new automatic external cardioverter-defibrillator. J Am Coll Cardiol 2003;41(4):627-32; Mattioni T, Kanaan N, Riggio D, Bahu M, Lin D, Welch S, et al. Performance of an automatic external-cardioverter-defibrillator algorithm in the discrimination of supraventricular from ventricular tachycardia. Am J Cardiol 2003;91:1323-6] and improve outcomes [Martinez-Rubio A, Kanaan N, Borggrefe M, Block M, Makijarvi M, Fedele F, et al. Advances in treating in-hospital cardiac arrest: safety and effectiveness of a new automatic external cardioverter-defibrillator. J Am Coll Cardiol 2003;41(4):627-32]. There is, however, no guidance or standard about their use in the UK. This paper presents the results of a study, which explored clinicians' experiences and perceptions of using FAEDs in acute care in the UK.

AIMS

This study sought to understand clinicians' experiences and perceptions of the use of FAEDs in acute care and their impact on decision making.

METHODS

Using a qualitative approach, 43 nurses and four physicians were included in a trial of FAEDs in a Coronary Care Unit (CCU) and cardiology ward during 2004. Semi-structured interviews were conducted with nurses and physicians prior to and following the trial. Data were analysed using thematic analysis [Attride-Stirling J, Thematic networks: an analytic to research. Qual Res 2001;1(3):385-405].

RESULTS

Decision control, safety, a lack of confidence in the technology, previous experience and concerns about the psychological affect on patients affected clinicians' decision making and limited the use of the FAED.

CONCLUSION

Despite reported benefits of the FAED [Martinez-Rubio A, Kanaan N, Borggrefe M, Block M, Makijarvi M, Fedele F, et al. Advances in treating in-hospital cardiac arrest: safety and effectiveness of a new automatic external cardioverter-defibrillator. J Am Coll Cardiol 2003;41(4):627-32; Mattioni T, Kanaan N, Riggio D, Bahu M, Lin D, Welch S, et al. Performance of an automatic external-cardioverter-defibrillator algorithm in the discrimination of supraventricular from ventricular tachycardia. Am J Cardiol 2003;91:1323-26], personal and contextual issues affected the clinicians' decision making. More and better understanding about how FAEDs and their context of use may challenge established practice is required in order that it is utilised in the most effective way.

Health-related quality of life of patients with implantable cardioverter defibrillators compared with that of pacemaker recipients

AIMS

Studies indicate a poorer quality of life (QoL) for implantable cardioverter defibrillator (ICD) patients than for the general population. However, studies comparing the QoL of ICD patients with that of patients with other implantable cardiac devices are scarce. We hypothesized that ICD patients had a poorer QoL than pacemaker patients.

METHODS AND RESULTS

All ICD patients living in Iceland at the beginning of 2002 (44 subjects), and a comparison group of 81 randomly selected patients with pacemakers were invited to participate. The Icelandic Quality of Life Questionnaire (IQL), the General Health Questionnaire (GHQ), the Beck Anxiety Inventory (BAI), and the Beck Depression Inventory (BDI) were submitted to measure QoL, psychiatric distress, and symptoms of anxiety and depression. The ICD and pacemaker groups did not differ on IQL, BAI, BDI, or GHQ scores. ICD patients were as a group more fearful of death (P = 0.056) and showed more concerns about returning to work (P = 0.072), although these items fell just short of statistical significance.

CONCLUSION

Contrary to our expectations, ICD patients had a comparable QoL with pacemaker recipients and were not more likely to suffer from anxiety, depression, or general psychiatric distress. These findings are encouraging in view of expanding ICD indications.

Amiodarone Therapy in Patients Implanted With Cardioverter-Defibrillator for Life-Threatening Ventricular Arrhythmias

BACKGROUND

Whether amiodarone can improve the patient's clinical outcome by reducing implantable cardioverter-defibrillator (ICD) therapy deliveries for ventricular tachycardia or fibrillation (VT/VF) has not been clearly evaluated.

METHODS AND RESULTS

A total of 507 patients with VT/VF due to organic heart disease who had ICDs implanted were enrolled in this study. The patients were divided into 3 groups: Amiodarone (n=247), Class I anti-arrhythmic drug (n=103) and CONTROL (n=157) groups, and the total cause mortality and arrhythmic event free survival rates were evaluated between the groups. The mean follow-up period was 38+/-27 months. The left ventricular ejection fraction was significantly decreased in the Amiodarone group (Amiodarone: 37+/-15%; Class I: 39+/-16%;

CONTROL

44+/-17%). The mortality and arrhythmic events were significantly higher in the Class I group than the Amiodarone group (p<0.05), but there was no significant difference between the Amiodarone and CONTROL groups (arrhythmic event free rate at 5 years: Amiodarone: 53%; Class I: 35%;

CONTROL

48%; 5 year survival: 86%, 74% and 77%, respectively). Side effects from amiodarone were found in 12% of the patients, but no fatal events were observed.

CONCLUSIONS

The present study could not demonstrate the benefit of amiodarone in ICD patients, probably due to a significant clinical bias exerted in selecting this drug.

Benefits of cardiac rehabilitation in patients with implantable cardioverter-defibrillators: a patient survey

OBJECTIVES

To determine whether participation in an outpatient cardiac rehabilitation (OCR) program increases exercise levels and decreases shocks in patients with implantable cardioverter-defibrillators (ICDs).

DESIGN

Retrospective comparative survey.

SETTING

University tertiary-care ICD clinic.

PARTICIPANTS

Patients with ICDs and coronary artery disease.

INTERVENTION

Participation in OCR (nonrandomized).

MAIN OUTCOME MEASURES

Exercise levels and OCR participation were determined through a telephone survey of patients with ICDs. The incidence of shock-treated arrhythmia was determined by review of charts and ICD data storage disks.

RESULTS

Of 82 patients (85% men; mean age, 61+/-8 y), 28 (34%) participated in OCR after receiving an ICD. There was no difference in age, sex, ejection fraction, or length of follow-up between OCR and non-OCR groups. Median intensity of regular exercise was 5.3 metabolic equivalents (METS) for OCR patients versus 3.5 METS for non-OCR patients (P<.02). In follow-up (mean, 48+/-3 mo), non-OCR patients were more likely to receive any shock, shocks during exercise, or shocks for ventricular arrhythmia during exercise than OCR patients (all P<.05). Non-OCR remained a predictor of shock after adjustment for exercise limitation (P<.05).

CONCLUSIONS

OCR patients exercised more and had fewer shocks. Physicians and health plans should encourage ICD patients to participate in OCR.

Sexual concerns and educational needs after an implantable cardioverter defibrillator

BACKGROUND

Patients with an implantable cardioverter defibrillator (ICD) describe anxiety, fears, and other psychosocial issues, although sexual concerns are not well understood.

PURPOSE

The purpose of this descriptive study was to explore the experiences of patients and partners with return to sexual activity post-ICD implantation.

PARTICIPANTS

Subjects were 12 patients with an ICD (10 men, 2 women) and 4 partners (1 man, 3 women). Most patients with an ICD and partners were age 55 years or older, with a mean age of 62 years for patients and 47 years for partners.

METHODS

A semistructured interview was used to explore the meaning and influence of the ICD on the sexual relationship. Interviews were recorded, transcribed verbatim, and analyzed using a qualitative descriptive approach.

RESULTS

Themes identified were (1) anxiety and apprehension, with subthemes of partner overprotectiveness and fear of ICD discharge with sexual activity; (2) varying interest and pattern of sexual activity; (3) powerfulness of ICD discharge; and (4) a need for information and sexual counseling.

IMPLICATIONS

Additional research is needed to further understand the experience of ICD discharge with sexual activity and to develop educational strategies.

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.

Psychosocial Issues of Patients With Implantable Cardioverter Defibrillators

Use of implantable cardioverter defibrillators has become standard therapy for patients at high risk for life-threatening ventricular arrhythmias. Although acceptance of the device is generally high among patients and their families, quality of life and psychosocial issues associated with use of the defibrillators deserve greater attention to improve outcomes. Psychosocial issues, their ramifications, and theory-and evidence-based approaches to improving outcomes are described.

Technology-patient interactions: Internet use for gaining a healthy context for living with an implantable cardioverter defibrillator

OBJECTIVE

The purpose of this study was to understand the practical knowledge gained from Internet use by implantable cardioverter defibrillator (ICD) recipients through hermeneutic interpretation of narrative stories.

METHODS

The study took place through an online virtual focus group and e-mail interviews. Thirteen participants attended the ongoing 4-week virtual focus group, and 8 followed up with individual interviews.

RESULTS

Five related themes and 1 constitutive pattern emerged. Themes included getting past fear with knowledge and support; gaining context through a window to the future; Internet as mountain of information; and Internet as social interaction and becoming informed consumers. The constitutive pattern was gaining a context for living a healthy life with an ICD.

IMPLICATIONS

Providers must be aware of the value added when patients use the Internet for self-care management of their chronic illness. Through information searches and sharing stories, patients gain insight into possibilities and potential outcomes of living with an ICD.

Electrophysiologic Study‐Guided Therapy with Sotalol for Life‐Threatening Ventricular Tachyarrhythmias

The aim of this study was to investigate the long-term efficacy and safety of electrophysiologic study (EPS)-guided sotalol administration combined with implantable cardioverter defibrillators (ICD) for ventricular tachyarrhythmias (VTA). This study enrolled 92 patients with both structural heart disease and sustained VTA. Sotalol was administered to 57 patients, and its efficacy was assessed by EPS. Long-term treatment was continued in combination with ICD in 31 patients (57%) whose VTA was no longer inducible (responder group) and in 16 patients whose VTA remained inducible (nonresponder group). The long-term outcomes were compared among the responder group, the nonresponder group, and 35 ICD recipients untreated with antiarrhythmic drugs (ICD-only group). During a mean follow-up of 44 +/- 33 months, the recurrence of VTA was not significantly different between all patients treated with sotalol (30%) and patients in the ICD-only group (46%). However, the recurrence of VTA was significantly lower in the responder (13%) than in the nonresponder (63%) or the ICD-only groups (46%). There was no significant difference in VTA recurrence between the nonresponder and the ICD-only groups. One patient each in the responder and the ICD-only groups died suddenly, and all-cause mortality was similar in the three groups. The incidence of inappropriate ICD discharges was less in the sotalol than in the ICD-only groups. No patient had to discontinue long-term sotalol treatment because of the adverse effects. In conclusion, sotalol reduced VTA recurrence in the responding patients and inappropriate ICD discharge. EPS may predict the efficacy of sotalol for VTA recurrence.

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.

Panic disorders and agoraphobia: side effects of treatment with an implantable cardioverter/defibrillator

BACKGROUND

Implantable cardioverter/defibrillator (ICD) treatment has reduced the mortality of patients with a high risk of sudden cardiac death. However, ICD discharges may cause anxiety with respect to new discharges and lead to preventive, for example, phobic, behavior. This study evaluated the frequency of panic disorders and agoraphobia in patients with ICD and assessed the risk factors in their development.

HYPOTHESIS

Treatment with ICD represents a risk factor in the development of anxiety disorders.

METHODS

Ninety patients with ICD were examined using a standardized lifetime Diagnostic Interview of Psychiatric Syndromes (DIPS). This interview makes it possible to estimate the incidence of panic disorders and agoraphobia. The impact of the severity of the underlying cardiac disease, the number of ICD discharges, and the subjective appraisal of the shock experience on the development of panic disorders and agoraphobia was assessed.

RESULTS

Fifteen patients (16.7%) developed anxiety disorders after ICD implantation. The incidence was 21% in patients with and 6.9% in patients without ICD discharge. In patients with two or more ICD discharges annually, the incidence of panic disorders and agoraphobia was higher than that in patients with a single ICD discharge annually (62 vs. 10%, p<0.01). The intensity of self-observation of their body was significantly related to the development of anxiety disorders (p<0.001).

CONCLUSION

Panic disorders and agoraphobia are frequent side effects of ICD treatment. Risk factors in the development of these disorders are two or more ICD discharges annually and a negative cognitive appraisal of ICD discharges. Therapeutic efforts should aim at reducing the number of ICD discharges and provide early psychological treatment.

Radiofrequency ablation for post infarction ventricular tachycardia

Radiofrequency ablation has an important role in the management of post infarction ventricular tachycardia. The mapping and ablation of ventricular tachycardia (VT) is complex and technically challenging. In the era of implantable cardioverter defibrillators, the role of radiofrequency ablation is most commonly reserved as an adjunctive treatment for patients with frequent, symptomatic episodes of ventricular tachycardia. In this setting the procedure has a success rate of around 70-80% and a low complication rate. With improved ability to predict recurrent VT and improvements in mapping and ablation techniques and technologies, the role of radiofrequency ablation should expand further.

Azimilide decreases recurrent ventricular tachyarrhythmias in patients with implantable cardioverter defibrillators

OBJECTIVES

This study evaluated the effects of azimilide dihydrochloride (AZ) on anti-tachycardia pacing (ATP) and shock-terminated events in patients with implantable cardioverter defibrillators (ICDs).

BACKGROUND

Animal studies have shown the effectiveness of AZ for therapy of supraventricular and ventricular tachycardia (VT). Azimilide dihydrochloride was investigated as adjunctive treatment for reducing the frequency of VT and, thus, the need for ICD therapies, including ATP and cardioversion/defibrillation (ICD shocks) in patients with inducible monomorphic VT.

METHODS

A total of 172 patients were randomized to daily treatment with placebo, 35 mg, 75 mg, or 125 mg of oral AZ in this dose-ranging pilot study of patients with ICDs. The majority of patients had a history of documented remote myocardial infarction and congestive heart failure New York Heart Association class II or III.

RESULTS

The frequency of appropriate shocks and ATP were significantly decreased among AZ-treated patients compared with placebo patients. The incidence of ICD therapies per patient-year among the placebo group was 36, and it was 10, 12, and 9 among 35 mg, 75 mg, and 125 mg AZ patients, respectively (hazard ratio = 0.31, p = 0.0001). Azimilide dihydrochloride was generally well tolerated and did not affect left ventricular ejection fraction or minimal energy requirements for defibrillation or pacing.

CONCLUSIONS

Azimilide dihydrochloride may be a safe and effective drug for reducing the frequency of VT and ventricular fibrillation in patients with implanted ICDs.

Psychosocial aspects of patient-activated atrial defibrillation

Atrial Defibrillator.

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSION

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

Psychological therapies for recipients of implantable cardioverter defibrillators

Implantable Cardioverter Defibrillators (ICDs) are an increasingly common therapy for the treatment of ventricular arrhythmias. Whereas most ICD recipients adjust well to living with the implant, a substantial minority suffer anxiety, depression, and anger that appears to be related to the ICD. A large number of studies have reported on the incidence of psychopathology and common psychosocial problems among patients with ICDs, however very few psychological interventions with this cohort have been reported. In an extensive literature search we identified only a handful of studies that described outcomes of psychological interventions, and most of these were in pilot form. Only one randomized controlled study with a homogenous sample of ICD patients has been reported to date. Given the unique situation of patients with ICDs and the particular vulnerability of those who experience frequent shocks, the evaluation of interventions that may improve psychological adjustment within this group would appear a worthwhile endeavor.

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.

Comprehensive cardiac rehabilitation programme for implantable cardioverter-defibrillator patients: a randomised controlled trial

OBJECTIVE

To investigate the effects of a 12 week comprehensive cardiac rehabilitation (CCR) programme on patients who have undergone implantation of an implantable cardioverter-defibrillator (ICD).

DESIGN

Sixteen patients with ICDs (14 (88%) male, mean (SD) age 58 (10) years, range 34-74 years) were randomised to either attend an individually tailored CCR programme or receive usual care. They then changed to the alternative regimen for a further 12 weeks. Exercise capacity was assessed using a treadmill exercise test at baseline, after usual care, after CCR and 12 weeks after CCR to assess maintenance effects. Hospital anxiety and depression (HAD) scores were recorded at each stage.

RESULTS

Exercise times (min:s; mean (SD)) increased by 16% from a baseline mean of 9:55 (2:33) to 11:11 (2:17) following attendance at CCR (95% confidence interval (CI) 0:34 to 1:58; p = 0.001). This improvement was maintained 12 weeks after attendance at CCR, at 11:20 (2:17) (p = 1.00). HAD scores for anxiety and depression decreased during CCR from a baseline of 13.4 (3.6) to 8.1 (3.6), 95% CI 3.5 to 7.0 (p < 0.001) and 9.9 (3.4) to 6.7 (2.9), 95% CI 1.9 to 4.4 (p = 0.002), respectively. These improvements were maintained at 12 weeks after CCR. No ventricular arrhythmias or ICD discharges occurred during the exercise components of the CCR. The total number of ventricular arrhythmias and ICD discharges was similar 12 weeks before, during, and 12 weeks after CCR.

CONCLUSIONS

CCR appears to be safe for patients with ICDs. It can improve exercising ability and lower the levels of psychological distress. A larger multicentre study is recommended to confirm these findings.