Cognitive-behavioural rehabilitation programme for patients with an implanted cardioverter defibrillator: A pilot study

OBJECTIVES

The effectiveness of a comprehensive 12-week CR programme for ICD patients was evaluated.

DESIGN

All surviving and suitable ICD patients being cared for by a regional implantation centre were invited to attend a 12-week cognitive-behavioural cardiac rehabilitation programme that had been modified to meet the needs of this group. Patients assenting were randomized to either an immediate treatment or a waiting treatment group. Measures were taken prior to randomization, at the end of the treatment or waiting period, at the end of the second treatment group for that group only and at three months post-treatment for both groups.

OUTCOME MEASURES

The Hospital Anxiety and Depression Scale, the Total Concerns Questionnaire, the Quality of Life after Myocardial Infarction Questionnaire, the EuroQual (subjective health rating scale), the Shuttle Test and a number of ICD shocks and ATP episodes were used in this study.

RESULTS

For those patients willing and able to attend, the cognitive-behavioural CR programme produced significant benefits in terms of psychological and functional adaptation to living with the device.

CONCLUSIONS

A comprehensive 12-week CR programme that incorporated both psychological and exercise-based components significantly reduced anxiety and depression and improved quality of life of ICD patients. It is not clear if these benefits are sustained.

Was darf ein ICD-Träger und was nicht?

Patients with an implantable cardioverter defibrillator (ICD) may experience loss of consciousness. Electromagnetic interference (EMI) may trigger undesired or inhibit necessary therapy in patients with an ICD. Therefore, questions about personal or professional activities for ICD patients arise. Restricting driving or other personal activities has adverse effects on the patient's quality of life. The national Societies of Cardiology provide recommendations for ICD patients concerning driving of motor vehicles. Patients with an ICD that is implanted prophylactically do not have to refrain from driving after recovery from the implantation procedure. Patients with arrhythmias are classified into different groups depending on the risk of recurrence of tachycardias and symptoms. Commercial driving is not allowed for patients with an ICD in Germany except for those with a prophylactic indication without a history of arrhythmias. Those patients may drive small cars but no trucks or busses. Guidelines for medical fitness in commercial or military flying are regulated by the Joint Aviation Authorities (JAA) and ventricular tachycardias are a contraindication for both. Fortunately, loss of consciousness is not dangerous in most jobs. Strong sources of EMI can occur at special workplaces. Patients have to be advised and tested individually concerning their risk for EMI at their employment site before returning safely. Modern life exposes to an increasing amount of EMI. Intact household devices usually do not interfere with ICDs. Mobile phones may interfere with implanted devices. Interaction can be minimized by special precautions like maintaining a distance of minimum 10 cm between mobile phone and ICD. Electronic surveillance systems work differently and have the potential to interact with devices. Patients should be advised to pass those systems with avoiding longer exposure. The presence of an ICD is presently a contraindication for undergoing magnetic resonance imaging (MRI) because of a high risk of destruction of the system with even potential harm to the patient. High-frequency application for electrocautery devices or ablation is possible under certain precautions that have to be planned before. There is a high sensitivity of ICD systems to ionizing radiation with defect of the devices after a cumulative dose > 5 Gy.

Effect of exercise training in patients with an implantable cardioverter defibrillator

AIMS

Little research exists on exercise performance and training in patients with an implemented cardioverter defibrillator (ICD) and only in a limited number of patients. This study aims to investigate the effect of exercise training in ICD patients in comparison to the effects in other cardiac patients without an ICD.

METHODS AND RESULTS

92 ICD patients were compared with a control group of 473 patients. A maximal cycle-spiroergometric test was performed until exhaustion before and after an ambulatory exercise training programme. Exercise training was offered 3 times a week for 3 months. The cut-off heart rate was set at (ICD detection rate -20 beats/min). At baseline, the ICD patients had a lower peak oxygen uptake (VO(2)) compared to the control group. Training effects were smaller for peak VO(2) (mL/min/kg) and oxygen pulse in the ICD group (18 vs. 27%, p = 0.006 and 11 vs. 17%, p = 0.016, respectively). Several appropriate shocks were delivered during (n = 5), and in between (n = 7), testing or training and one inappropriate shock during training.

CONCLUSIONS

ICD patients can safely participate in an exercise training programme with favorable results. A randomised control study with evaluation of the physical and the psychosocial effects is warranted.

Clustering and the design of preference-assessment surveys in healthcare

OBJECTIVE

To show cluster analysis as a potentially useful tool in defining common outcomes empirically and in facilitating the assessment of preferences for health states.

DATA SOURCES

A survey of 224 patients with ventricular arrhythmias treated at Kaiser Permanente of Northern California.

STUDY DESIGN/METHODS

Physical functioning was measured using the Duke Activity Status Index (DASI), and mental status and vitality using the Medical Outcomes Study Short Form-36 items (SF-36). A "k-means" clustering algorithm was used to identify prototypical health states, in which patients in the same cluster shared similar responses to items in the survey.

PRINCIPAL FINDINGS

The clustering algorithm yielded four prototypical health states. Cluster 1 (21 percent of patients) was characterized by high scores on physical functioning, vitality, and mental health. Cluster 2 (33 percent of patients) had low physical function but high scores on vitality and mental health. Cluster 3 (29 percent of patients) had low physical function and low vitality but preserved mental health. Cluster 4 (17 percent of patients) had low scores on all scales. These clusters served as the basis of written descriptions of the health states.

CONCLUSIONS

Employing a clustering algorithm to analyze health status survey data enables researchers to gain a data-driven, concise summary of the experiences of patients.

[Driving restrictions for arrhythmia patients--with special reference to the implantable cardioverter/defibrillator]

The series "Illness and Vehicular Traffic", published by the German Federal Ministry for Transportation, has set forth the following guidelines on the subject of driving for patients with cardiac rhythm disorders: "Anyone suffering from disorders of cardiac rhythm which might, on occasion, lead to the repeated interruption of oxygen supply to the brain and thus cause disturbances in consciousness or even loss of consciousness, must be considered unsuitable for driving a motor vehicle of any class." While these guidelines are essentially indisputable, it remains unclear how they affect patients with an implantable cardioverter/defibrillator (ICD). The issue is further complicated by the fact that these patients, as a rule, suffer from malignant and life-threatening cardiac rhythm disorders, often owing to a severe cardiac disorder (primarily coronary heart disease and cardiomyopathy). It was the purpose of a recent study to investigate how medical permission to drive in ICD patients is handled in various European countries. A specifically designed questionnaire was addressed to 46 European National Delegates of the Working Groups on Cardiac Pacing in order to determine their present practices and criteria utilized when advising driving restrictions to patients (pts) after ICD implantation.

RESULTS

Of the 39 (83%) respondents, 22 (56%) cardiologists advised all pts to abstain from driving. Permanent driving abstinence was advised by 13 (33%) of the responding cardiologists, while temporary driving abstinence for periods of 3 to 18 months (mean 9 +/- 4 months) was recommended by 26 (67%) physicians. Criteria for subsequently advising a longer period of driving abstinence were: presyncope by 15 (38%), syncope by 13 (33%) and multiple shocks by 2 (5%) cardiologists. Despite medical advice not to drive, about one-third of pts resume driving. About half of the pts resumed driving after 6 months, with the vast majority driving 12 months after ICD implantation. Two pts experienced ICD discharges while driving, but no motor vehicle accident occurred. One patient had a motor vehicle collision with a fatal outcome which was not caused by loss of consciousness or ICD discharge.

CONCLUSIONS

1) Fatal accidents of ICD discharges while driving are a rare finding in ICD pts. 2) About half of the physicians always advise their pts to cease driving for a period of 9 +/- 4 months. Despite this medical advice pts resume driving 6 months after ICD implantation. 3) Criteria used in advising driving abstinence are not uniform among physicians. In symptomatic bradyarrhythmias the driving privilege may be reinstated after pacemaker implantation provided that symptoms resulting from the interruption of the oxygen supply to the brain have not recurred.