Implantable cardioverter defibrillators (ICDs) have been shown to prevent life-threatening ventricular arrhythmias, but recipients can sometimes have dramatic experiences resulting from care. Each month, about 10,000 Americans have ICDs implanted to restore normal heart rhythm and prevent sudden cardiac death. “Many people who experience cardiac arrhythmias are surprised to learn of their potentially life-threatening condition,” explains Sandra B. Dunbar, RN, DSN, FAAN, FAHA. “Patients and their family are often forced into critical medical decision making and required to confront and cope with their condition. They need to be educated on their treatment options and adjust to the fact that they need an ICD.”
Studies have shown that ICDs can significantly improve survival and quality of life (QOL), but the underlying arrhythmia and its treatment may be accompanied by adverse psychological responses. “These responses may be underappreciated in some cases and warrant greater attention by healthcare providers,” says Dunbar. “Focusing on ways to optimize psychological outcomes for those who are considering or receiving an ICD is paramount.” Psychological outcomes are an important component of QOL and reflect an aspect of the costs and benefits beyond simply living longer.”
“Focusing on ways to optimize psychological outcomes for those who are considering or receiving an ICD is paramount.”
In an issue of Circulation, Dunbar and colleagues at the American Heart Association (AHA) had a scientific statement published that provides an evidence-based comprehensive review of psychosocial considerations and QOL for people who receive ICDs. The statement also describes the concerns and educational needs of ICD patients and their families and outlines evidence supporting interventions for improving educational and psychological outcomes for these patients. Recommendations for improving psychosocial outcomes are also provided so that the benefits of using ICDs can be maximized (Table).
Education & Support for ICD Recipients
Dunbar, who chaired the AHA committee that developed the scientific statement, says that education and support for ICD recipients must include patients and their families and be broader than simply focusing on maintaining the device. “Depression, anxiety, and PTSD are common among people with ICDs, so routine screening and appropriate treatment for these conditions are recommended.”
The statement adds that doctors and nurses should provide gender- and age-specific information on the potential psychological impact. Helping patients address ICD-specific concerns about symptoms, heart disease treatment, physical activities, and end-of-life issues is also key. The AHA notes that clinicians should provide clear information about the benefits and limitations of ICDs before implanting them. The patient’s prognosis and the impact of receiving ICDs on lifestyle should also be clearly explained.
Follow-Up & Monitoring of ICD Recipients
Close monitoring and follow-up are important components to optimizing psychological outcomes among ICD recipients, according to Dunbar. “At each follow-up visit, we should be assessing patient concerns and psychological status. Extra efforts may be required to help patients and their families deal with the stressful situations that may develop as a result of getting an ICD.”
When patients experience an ICD shock, the event can be distressing. “Patients can have a wide variety of responses to shocks,” Dunbar says. “While some are reassured because they recognize that the ICD is working, others find the physical sensations frightening and overwhelming. To improve psychological outcomes, physicians and nurses should work with patients and their families to develop a clear shock plan so they know what to do in the event of a shock.” The AHA also recommends that clinicians provide an ongoing assessment of ICD patients’ psychological needs.
ICD patients can expect generally desirable QOL as long as they are not exposed to excessive, unnecessary, or repeated ICD shocks, according to the AHA statement. “Most ICD patients derive other benefits in addition to the mortality benefit without compromising QOL,” says Dunbar. The underlying cardiac disease, associated symptoms, and physical limitations caused by heart failure are other important considerations in QOL outcomes.
More to Come on ICD Use
Dunbar says that more study is needed on the pathways that link psychosocial distress and ventricular arrhythmias to ICD shocks. “Finding ways to predict which patients are likely to experience psychological distress and how to alleviate it is important in future research. We also need to learn more about the most appropriate levels of physical activity for children and teenagers with ICDs. Another area that requires more study is when and how to discuss potential ICD deactivation near the end of life. As clinicians become more cognizant of the need for providing greater psychosocial support in the various stages of ICD implantation, it’s hoped that patients who need these devices and their families will experience benefits in psychological outcomes.”
Readings & Resources (click to view)
Dunbar SB, Dougherty CM, Sears SF, et al; on behalf of the American Heart Association Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Council on Cardiovascular Disease in the Young. Educational and psychological interventions to improve outcomes for recipients of implantable cardioverter defibrillators and their families: a scientific statement from the American Heart Association. Circulation. 2012;126:2146-2172. Available at: http://circ.ahajournals.org/content/early/2012/09/24/CIR.0b013e31825d59fd.full.pdf+html.
Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation /American Heart Association Task Force on Practice Guidelines. Circulation. 2012 Sep 10 [Epub ahead of print]. Available at: http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0b013e3182618569.
Sears SF, Matchett M, Conti JB. Effective management of ICD patient psychosocial issues and patient critical events. J Cardiovasc Electrophysiol. 2009;20:1297-1304.
Kurtz SM, Ochoa JA, Lau E, et al. Implantation trends and patient profiles for pacemakers and implantable cardioverter defibrillators in the United States: 1993-2006. Pacing Clin Electrophysiol. 2010;33:705-711.
LaPointe NMA, Al-Khatib SM, Piccini JP, et al. Extent of and reasons for nonuse of implantable cardioverter defibrillator devices in clinical practice among eligible patients with left ventricular systolic dysfunction. Circ Cardiovasc Qual Outcomes. 2011;4:146-151.
Stewart GC, Weintraub JR, Pratibhu PP, et al. Patient expectations from implantable defibrillators to prevent death in heart failure. J Card Fail. 2010;16:106-113.
Burke JL, Hallas CN, Clark-Carter D, et al. The psychosocial impact of the implantable cardioverter defibrillator: a meta-analytic review. Br J Health Psychol. 2003;8:165-178.
Kapa S, Rotondi-Trevisan D, Mariano Z, et al. Psychopathology in patients with ICDs over time: results of a prospective study. Pacing Clin Electrophysiol. 2010;33:198-208.