Original-clinicalPsychosocial status predicts mortality in patients with life-threatening ventricular arrhythmias
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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Cited by (34)
Patient-Reported Quality of Life as a Predictor of Mortality and Ventricular Tachyarrhythmia's During 7 Years’ Follow-Up in Patients With an Implantable Cardioverter Defibrillator (from the MIDAS Study)
2019, American Journal of CardiologyCitation Excerpt :Only social functioning, y but none of the other QoL dimensions, was associated with risk for VTa's during the follow-up period, with better social functioning associated with a 32% reduced risk. Our findings are in line with results of earlier studies that used secondary data from the MADIT II13 and AVID trials11,12 that had shorter follow-up periods (range 1 to 3 years). In the MADIT II trial based on data from 1,058 patients,13 lower scores on the MCS and PCS of the SF-36 were associated with a 39% and 89% higher mortality risk at 12 months’ follow-up, respectively.
DenHeart: Differences in physical and mental health across cardiac diagnoses at hospital discharge
2017, Journal of Psychosomatic ResearchCitation Excerpt :QoL and anxiety scores seem to provide important prognostic information, independent of traditional clinical data. High QoL scores and low anxiety scores have been associated with longer survival in patients with e.g. ventricular arrhythmias and coronary artery disease [6–8]. Furthermore, psychosocial factors account for 39% of the risk of myocardial infarction, and an overwhelming 67% in women alone, whereas smoking accounts for 29%, hypertension 21% and lipids 45% [9].
Psychological correlates, allostatic overload and clinical course in patients with implantable cardioverter defibrillator (ICD)
2016, International Journal of CardiologyCitation Excerpt :To our knowledge, only a small study [31] assessed DCPR syndromes among patients with ICD. Only few studies have examined the role of baseline psychological characteristics such as anxiety [31], type D personality and self-reported health-related quality of life [10,24,32,33] as risk factors for ventricular arrhythmias and death in ICD patients. The present study aims to describe the baseline psychological and psychosomatic profile of patients undergoing the implantation of ICD, focusing on acute and chronic distress, and evaluate if these psychological variables could affect the clinical course of ICD patients.
The distressed (Type D) personality in both patients and partners enhances the risk of emotional distress in patients with an implantable cardioverter defibrillator
2011, Journal of Affective DisordersCitation Excerpt :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).
Health-Related Quality of Life Scores and Values as Predictors of Mortality: A Scoping Review
2023, Journal of General Internal MedicineEffect of a Home-Based Mobile Health App Intervention on Physical Activity Levels in Patients With Heart Failure: A Randomized Controlled Trial
2023, Journal of Cardiovascular Nursing
The AVID investigators and their affiliations are listed in reference 17.
This manuscript was processed by a guest editor.