Elsevier

Heart Rhythm

Volume 5, Issue 3, March 2008, Pages 361-365
Heart Rhythm

Original-clinical
Psychosocial status predicts mortality in patients with life-threatening ventricular arrhythmias

https://doi.org/10.1016/j.hrthm.2007.11.010Get rights and content

Background

Quality-of-life (QoL) instruments evaluate various aspects of physical, mental, and emotional health, but how these psychosocial characteristics impact long-term outcome after cardiac arrest and ventricular tachycardia (VT) is unknown.

Objective

The purpose of this study was to evaluate the relationship of baseline QoL scores with long-term survival of patients enrolled in the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial.

Methods

Formal QoL measures included SF-36 mental and physical components, Patient Concerns Checklist, and Ferrans and Powers Quality-of-Life Index–Cardiac Version. Multivariate Cox regression was used to assess the association of survival and these measures, adjusting for index arrhythmia type, gender, race, age, ejection fraction, history of congestive heart failure, antiarrhythmic therapy, and beta-blocker use.

Results

During mean follow-up of 546 ± 356 days, 129 deaths occurred among 740 patients. Higher baseline SF-36 physical summary scores (P <.001), higher baseline QoL Index summary scores (P = .015), and lower baseline Patient Concerns Checklist summary scores (P = .047) were associated with longer survival, even after adjustment for clinical variables. When QoL measures were examined simultaneously, only the SF-36 physical summary score remained significant (P = .002).

Conclusion

During recovery after sustained VT or cardiac arrest, formal baseline QoL assessment provides important prognostic information independent of traditional clinical data.

Introduction

Substantial evidence now indicates that acute forms of mental stress can induce arrhythmic events in patients with coronary artery disease.1, 2, 3, 4, 5, 6, 7, 8 This observation is supported by substantial experimental animal literature, which has established that both acute and subacute forms of stress can alter ventricular fibrillation (VF) threshold and aggravate arrhythmia occurrence.7, 8 Chronic forms of psychological stress also may affect cardiac outcomes in patients with coronary artery disease,9, 10, 11, 12, 13, 14 but their role in precipitating arrhythmic events is not well known. The problem of addressing this issue is partly methodologic. A variety of potentially important psychosocial factors can be studied, such as depression, phobic anxiety, hostility, poor social support, and life stress. However, these factors are often clustered together and compounded by other important factors in patients at greatest risk for arrhythmic events, such as patients with congestive heart failure or those who previously experienced life-threatening arrhythmias. These patients are often physically debilitated or sensitized, which may introduce to the patients’ illness a very strong emotional component3, 10 that may override conventional psychosocial factors. Unless specifically addressed, the toll introduced by coping with life-threatening arrhythmias may not be well recognized by patients or physicians. In this regard, a state of demoralization characterized by dejection, fatigue, and irritability, referred to as “vital exhaustion,” has been shown to predict cardiac events in patients with coronary artery disease.12, 13, 14, 15, 16

Instruments that may be particularly well suited for following patients at risk for life-threatening arrhythmias are the health-related quality-of-life (QoL) indexes, which combine assessment of physical health, psychological stress, social support, and patients’ own perception of their sense of well-being. To date, the components of the QoL as they relate to patient outcome among patients at risk of life-threatening arrhythmias have not been well established in any clinical trial. Accordingly, we examined the value of patient-perceived psychosocial status from QoL results in predicting total mortality in patients from the prospective Antiarrhythmias Versus Implantable Defibrillators (AVID) trial who had experienced cardiac arrest or life-threatening ventricular tachycardia (VT).16, 17, 18, 19

Section snippets

AVID overview

The main AVID trial results have been published.17 Patients were enrolled in the randomized main AVID trial if they had experienced primary cardiac arrest due to VF, documented sustained VT with syncope, or documented sustained VT when left ventricular ejection fraction (EF) was <40 %, systolic blood pressure was <80 mmHg, and chest pain or near-syncope was present. Patients were randomized to receive antiarrhythmic drug therapy or an automated implantable cardioverter-defibrillator (ICD). A

Patient participants

All AVID participants were eligible for the QoL study; however, ultimately some did not contribute data to this study and other QoL analyses.20 Overall, baseline data from at least one of the QoL instruments were available for 740 patients; baseline QoL data were not available for 276 patients due to patient refusal, QoL administered after the randomization date (i.e., after baseline), or missing data. Table 2 details the clinical characteristics of the 740 subjects in the study. Compared to

Discussion

Among the patients of the AVID trial, our results indicate that a variety of QoL indexes predicted fatal events. Notably, these QoL measurements remained significant predictors after correcting for conventional clinical predictors, including left ventricular function and heart failure status. Hence, QoL scores appear to reflect a unique set of descriptors of characteristics that are associated with an adverse patient outcome in patients with a history of life-threatening ventricular arrhythmias.

Conclusion

Psychosocial characteristics predict fatal events in patients with serious ventricular arrhythmias. Therapeutic strategies, such as counseling, behavior modification, and rehabilitation, should be evaluated in clinical trials to determine whether patients at higher risk for death can be successfully identified and treated.

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      The implantable cardioverter defibrillator (ICD) is implanted in patients who have experienced a sudden cardiac arrest (secondary prevention) and in patients who are at risk for a sudden cardiac arrest, due to a decreased ejection fraction (primary prevention) (Epstein et al., 2008). The medical benefits of the ICD over pharmacological therapy are unequivocal in preventing sudden cardiac death in most patients (Ezekowitz et al., 2003), but adaptation problems exist in 25% to 33% of ICD patients who experience increased emotional distress (Bilge et al., 2006; Van den Broek et al., 2008), which in turn may trigger new life-threatening arrhythmias (Van den Broek et al., 2009; Whang et al., 2005) and influence survival (Ladwig et al., 2008; Steinberg et al., 2008; Pedersen et al., 2010). These emotional problems may be more related to the psychological profile of the patient than to clinical factors, such as indication for the ICD, ICD shocks, or an ICD advisory (Bilge et al., 2006; Pedersen et al., 2007, 2009a, 2010; Van den Broek et al., 2008).

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    The AVID investigators and their affiliations are listed in reference 17.

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