Samuel F. Sears

QUALITY OF LIFE AND PSYCHOLOGICAL FUNCTIONING OF ICD PATIENTS

The use of the implantable cardioverter-defibrillator (ICD) for life threatening ventricular arrhythmias is standard therapy, in large part because clinical trials data have consistently demonstrated its superiority over medical treatment in preventing sudden cardiac death.1 This success prompts closer examination and refinement of quality of life (QOL) outcomes in ICD patients. Although no universal definition of QOL exists, most researchers agree that “quality of life” is a generic term for a multi-dimensional health outcome in which biological, psychological, and social functioning are interdependent.2 To date, the clinical trials demonstrating the efficacy of the ICD have focused primarily on mortality differences between the ICD and medical treatment. While the majority of the QOL data from these trials is yet to be published, many small studies are available for review and support the concept that ICD implantation results in desirable QOL for most ICD recipients.3 In some patients, however, these benefits may be attenuated by symptoms of anxiety and depression when a shock is necessary to accomplish cardioversion or defibrillation. This paper reviews the published literature on QOL and psychological functioning of ICD patients and outlines the clinical and research implications of these findings. Definitive conclusions about QOL differences between patients managed with an ICD and those treated with antiarrhythmic drugs are difficult to make in the absence of large, randomised, controlled trials. Available evidence indicates that ICD recipients experience a brief decline in QOL from baseline but improve to pre-implant levels after one year of follow up.4 The largest clinical trial data published in final form is from the coronary artery bypass graft (CABG) Patch trial which randomised patients to ICD (n = 262) versus no ICD (n = 228) while undergoing CABG surgery.5 In contrast to May and colleagues,4 data from this trial indicate …

Strategies for improving maintenance of weight loss. Toward a continuous care model of obesity management.

The management of obesity represents an important objective in the care of many NIDDM patients. In recent years, progress has been made in increasing initial weight reductions, but poor long-term maintenance of weight loss remains a vital clinical concern. This article reviews the challenge of weight-loss maintenance and recommends the adoption of a continuous care model of obesity management. Strategies to improve the long-term maintenance of weight loss are described, and empirical tests of their effectiveness are reviewed. Collectively, the findings suggest that, after treatment for obesity, multifaceted programs comprised of continued professional contact, skills training, social support, and exercise, can enhance the long-term maintenance of weight loss.

Depression and anxiety in adult congenital heart disease: Predictors and prevalence

BACKGROUND Adult congenital heart disease (ACHD) patients face unique medical and social challenges that may contribute to psychological difficulties. The goals of this study were to identify predictors of symptoms of depression and anxiety and evaluate the prevalence of mood and anxiety disorders among North American ACHD patients. METHODS In this cross-sectional study, consecutive patients were recruited from two ACHD outpatient clinics. All patients completed self-report psychosocial measures and a subset was randomly selected to participate in structured clinical interviews. Linear regression models were used to predict symptoms of depression and anxiety. RESULTS A total of 280 patients (mean age=32 years; 52% female) completed self-report measures. Sixty percent had defects of moderate complexity and 31% had defects of great complexity. Significant predictors of depressive symptoms were loneliness (p<0.001), perceived health status (p<0.001), and fear of negative evaluation (p=0.02). Predictors of anxiety symptoms were loneliness (p<0.001) and fear of negative evaluation (p<0.001). Disease severity and functional class did not predict mood or anxiety symptoms. Fifty percent of interviewed patients (29/58) met diagnostic criteria for at least one lifetime mood or anxiety disorder, of whom 39% had never received any mental health treatment. CONCLUSIONS The results confirm an increased risk and under-treatment of mood and anxiety disorders in ACHD patients. Social adjustment and patient-perceived health status were more predictive of depression and anxiety than medical variables. These factors are modifiable and therefore a potential focus of intervention.

Educational and Psychological Interventions to Improve Outcomes for Recipients of Implantable Cardioverter Defibrillators and Their Families A Scientific Statement From the American Heart Association

Significant mortality benefits have been documented in recipients of implantable cardioverter defibrillators (ICDs); however, the psychosocial distress created by the underlying arrhythmia and its potential treatments in patients and family members may be underappreciated by clinical care teams. The disentanglement of cardiac disease and device-related concerns is difficult. The majority of ICD patients and families successfully adjust to the ICD, but optimal care pathways may require additional psychosocial attention to all ICD patients and particularly those experiencing psychosocial distress. This state-of-the-science report was developed on the basis of an analysis and critique of existing science to (1) describe the psychological and quality-of-life outcomes after receipt of an ICD and describe related factors, such as patient characteristics; (2) describe the concerns and educational/informational needs of ICD patients and their family members; (3) outline the evidence that supports interventions for improving educational and psychological outcomes for ICD patients; (4) provide recommendations for clinical approaches for improving patient outcomes; and (5) identify priorities for future research in this area. The ultimate goal of this statement is to improve the precision of identification and care of psychosocial distress in ICD patients to maximize the derived benefit of the ICD.

The ICD shock and stress management program: A randomized trial of psychosocial treatment to optimize quality of life in ICD patients

Background: Implantable cardioverter defibrillator (ICD) patients potentially face significant psychological distress because of their risk for life‐threatening arrhythmias and the occurrence of ICD shock.

Measurement of patient fears about implantable cardioverter defibrillator shock : An initial evaluation of the florida shock anxiety scale

Background: Psychological distress is both a precipitant and a consequence of ICD shock. Therefore, the assessment of patient anxiety and concerns related to receiving an ICD shock may prompt appropriate psychological referrals and treatment.

Young at Heart: Understanding the Unique Psychosocial Adjustment of Young Implantable Cardioverter Defibrillator Recipients

SEARS, S.F. JR., et al.: Young at Heart: Understanding the Unique Psychosocial Adjustment of Young Implantable Cardioverter Defibrillator Recipients. This article reviews the data related to psychosocial adjustment of young ICD recipients, postulates theories to explain potential adjustment difficulties to ICD therapy experienced by younger recipients, and suggests clinical management techniques for addressing the unique psychosocial concerns of young ICD recipients. Studies of young ICD recipients suggest that a wide range of psychosocial adjustment issues are prominent in the post‐ICD implantation period and that the issues may be different from older ICD recipients. The disability‐stress‐coping model and the transactional‐stress‐coping model are postulated as explanations for the unique adjustment concerns of children and adolescents with ICDs. Social comparison theory is also applied to the concerns of young adults with ICDs such that they often lack same age peers to compare experiences with cardiac difficulties. Brief, clinic‐based interventions by health care providers, like a screening and referral heuristic and an “ICD Buddy” system, are suggested to increase effective coping and decrease social isolation for young ICD recipients.

Posttraumatic Stress and the Implantable Cardioverter-Defibrillator Patient What the Electrophysiologist Needs to Know

The implantable cardioverter-defibrillator (ICD) has revolutionized the care of patients at risk for life-threatening arrhythmias. Large-scale clinical trials established mortality benefits for the ICD over usual care or medications1,2 and led to wider use for both primary and secondary prevention indications. More recent research confirms that the mortality benefits of the ICD extend over 8-year follow-up when compared with usual care.3 These clinical trial successes, in terms of mortality, have allowed for greater focus on patient-centered outcomes, such as quality of life, device acceptance, psychological well-being, and trauma reactions in research and clinical care.4 Shock has been a primary focus in this work because of its potentially traumatic impact on the patient experience. Although there is mixed evidence on the effect of single ICD shocks,5,6 the literature consistently supports the negative impact of >5 shocks on quality of life and emotional distress.7,8 ICD shock has been a focus of research interest because it is a unique experience for the ICD patient and can be perceived as a traumatic event. In addition, the existence of concomitant heart disease, angina, congestive heart failure, or previous sudden death may create sensitivity to traumatic stress that warrants improved understanding by attending electrophysiologists. Although psychological distress in ICD patients has been explored, the possibility that some ICD patients have trauma reactions, up to and including posttraumatic stress disorder (PTSD), has garnered increased attention recently. Therefore, the purposes of this report are to highlight the theory and research addressing psychological distress including PTSD in electrophysiology clinics, to discuss clinical management of these sequelae, and to suggest areas of future research and development. Prevention and identification of distress in ICD patients represents comprehensive, high-quality care, regardless of the cause (eg, depression, anxiety, trauma), consistent with the …

Effective Management of ICD Patient Psychosocial Issues and Patient Critical Events

The clinical management of implantable cardioverter‐defibrillator (ICD) patients involves successful medical and psychosocial care to reduce mortality and morbidity. Desirable quality of life (QoL) and psychosocial outcomes for ICD patients are achievable for a majority of ICD patients. Patient critical events, such as ICD shocks or ICD recalls, may occur that can dramatically alter the course of patient adjustment if not properly managed. Continuing care strategies that attend to patient critical events as they emerge may improve the psychosocial adjustment and improve the return to optimal daily functioning for ICD patients. This paper reviews QoL and psychosocial outcomes for ICD patients, patient critical events, and clinical implications for patient care. Patient critical events discussed in this paper include perioperative education, ICD shock events, device recalls, and end of life. The clinical management strategies for each of these patient critical events are suggested including patient education, psychosocial information provision, activity prescriptions, recall planning, and shock planning.

Appropriate Evaluation and Treatment of Heart Failure Patients After Implantable Cardioverter-Defibrillator Discharge: Time to Go Beyond the Initial Shock

Multiple clinical trials support the use of implantable cardioverter-defibrillators (ICDs) for prevention of sudden cardiac death in patients with heart failure (HF). Unfortunately, several complicating issues have arisen from the universal use of ICDs in HF patients. An estimated 20% to 35% of HF patients who receive an ICD for primary prevention will experience an appropriate shock within 1 to 3 years of implant, and one-third of patients will experience an inappropriate shock. An ICD shock is associated with a 2- to 5-fold increase in mortality, with the most common cause being progressive HF. The median time from initial ICD shock to death ranges from 168 to 294 days depending on HF etiology and the appropriateness of the ICD therapy. Despite this prognosis, current guidelines do not provide a clear stepwise approach to managing these high-risk patients. An ICD shock increases HF event risk and should trigger a thorough evaluation to determine the etiology of the shock and guide subsequent therapeutic interventions. Several combinations of pharmacologic and device-based interventions such as adding amiodarone to baseline beta-blocker therapy, adjusting ICD sensitivity, and employing antitachycardia pacing may reduce future appropriate and inappropriate shocks. Aggressive HF surveillance and management is required after an ICD shock, as the risk of sudden cardiac death is transformed to an increased HF event risk.