Psychological Management of the ICD Patient: What Have We Learned?

Tue, 2/9/10 - 9:52am
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Patricia Metoyer, MS, APN, Deborah Heart and Lung Center, Browns Mills, New Jersey

It is now well established that the implantable cardioverter defibrillator (ICD) is an accepted means of primary and secondary prevention in those patients who are at increased risk of sudden cardiac death, arrhythmias such as Brugada syndrome, and conditions due to primary cardiomyopathies and heart failure. The data supports increased survival rates and better quality of life (QOL) by improving the ability to participate in normal daily activities and exercise programs. However, because the implantation often occurs against a complex medical background with inevitable psychological stress, all implanted patients should be considered at high risk for developing psychopathology.1

The perceived impact and choice the patient is making between fear of prolonged illness such as chronic heart failure and the possibility of sudden cardiac death versus the fear of post-implant complications, ICD shocks, and device malfunction, causes stress and anxiety.2 This may be especially true of the patient who is undergoing implant due to primary prevention. These patients are accepting an unpleasant intervention when the benefit is uncertain for the future.3 Interestingly, patients who do accept their ICD had a supportive partner and a good attitude toward technology, and have reported improved quality of life.4 Those with underlying psychological pathology, older age, unanswered concerns, and serious disease rather than device indication, correlated with poor acceptance. There are other contributing factors such as culture and communication from the referring physician that affect acceptance.4

Kapa et al found that at baseline there are significant rates of psychopathology after implantation, but the scores improved over time. The group studied was similar in demographic makeup when compared to other study groups looking at anxiety, depression, and post-traumatic stress disorder (PTSD) following device implant. The study suggests that overall the dominance of depression, anxiety, and PTSD symptoms decreased over the one-year follow-up period. The rate of anxiety and depression were lower, but the rate of PTSD was comparable to other studies. An increase in the rate of PTSD was seen after ICD storms compared to those who did not have that experience.5 Greater than 10% of patients have persistently higher levels of anxiety, depression and PTSD scores one year post ICD implant, although even those scores improved from initial implant. Kapa et al suggest these findings propose that many undiagnosed psychopathological issues may be present at the time of implant for some recipients of ICD therapy.

An earlier study done by Carroll and Hamilton, which followed 41 patients over a 4-year period, concluded that mental health improved with reduced psychological distress by 6 months after implant, but physical functioning steadily declined over a 3- to 4-year period.6 Carroll suggests the reduction in physical functioning in this study may reflect the underlying cardiac disease that remained in this particular population of patients and their lack of participation in a cardiac rehabilitation program, as well as avoidance of exercise for fear of getting shocked.

References:

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