Multi-morbidity burden, psychological distress, and quality of life in implantable cardioverter defibrillator recipients: Results from a nationwide study
Introduction
Implantable cardioverter defibrillators (ICDs) are the first line therapy for individuals at higher risk for or with a prior history of ventricular arrhythmias [[1], [2], [3]]. The ICD is utilized for both primary and secondary prevention of sudden cardiac arrest, particularly in the context of heart failure [[4], [5], [6]]. According to the most recent global survey by the World Society of Arrhythmias, 222,407 new ICDs were implanted and 105,620 devices were replaced in 2009, the most recent year for which international data is available [7].
The prevalence of multi-morbidity in the ICD population is approximately 25% [8]. Multi-morbidity is defined in the literature as two or more significant medical conditions unrelated to the index condition [9,10]. Although multi-morbidity is defined by the existence of a number of chronic disease processes, it is not merely the sum of these diseases. Different conditions have varying levels of associated burden, but the negative effects of chronic illness are compounded by the addition of further comorbidities, increasing the level of disability and healthcare utilization [11]. The prevalence of multi-morbidity in ICD recipients has not been well studied. Reports of the prevalence of multi-morbidity in the general population have varied from 13 to 80% based upon the definition of multi-morbidity used by the researchers [9,10]. Multi-morbidity is associated with poor health outcomes in the ICD population [12,13]. This association between illness burden and poor health outcomes may affect ICD recipients' quality-of-life (QOL) and psychological responses to having an implanted device [8,14,15].
The links between individual chronic illnesses, QOL, and psychological response have been well studied, particularly in cardiovascular disease. However, models may not be generalizable to ICD recipients due to the complexity of implant indications and the existence of multiple comorbidities. ICD implantation occurs in individuals with multi-morbidities, yet little is known about the prevalence of multi-morbidity in ICD recipients and the often-complex interactions between ICDs and other chronic diseases on the psychological responses of this population. Therefore, the overall aim of this study was to determine the prevalence of anxiety and depressive symptoms, Type-D personality, and ICD-related concerns (e.g. worries about battery depletion or limitations due to therapy) in ICD recipients with varying levels of comorbidities, and to examine the association between multi-morbidity burden and QOL while controlling for sociodemographic, clinical, ICD-related, and psychosocial variables.
Section snippets
Study design, sample, and data collection
All adults listed in the Swedish ICD and Pacemaker Registry in 2012 who had an ICD with or without cardiac resynchronization therapy (CRT-D) implanted for at least one year were invited to participate in this study [[16], [17], [18], [19]]. There were no further inclusion or exclusion criteria except willingness to participate and return the informed consent document. The Swedish ICD and Pacemaker Registry is a national database, in which patients with a cardiac implantable electronic device
Multi-morbidity burden
Researchers had no access to patients' medical records; therefore, information on comorbidities was obtained via a self-report questionnaire. Multi-morbidity has often been measured by a simple count of multi-morbid conditions or a weighted count that consider the severity of each condition in the overall burden score [20], the latter was the case in our study. Our questionnaire listed 14 significant, common comorbidities (e.g., heart failure, diabetes, and cancer) for which participants
Statistical analyses
All statistical analyses were completed using SPSS version 22 (IBM Corp., Armonk, NY, USA). Characteristics were compared between categories of multi-morbidity based on quartile measurements in the sample (≤16; 17–19; 20–22; and ≥ 23) using X2 and ANOVA with post-hoc Bonferroni adjustment. The prevalence of anxiety and depressive symptoms, Type-D personality, and ICD-related concerns were compared between the four comorbidity burden groups.
We initially attempted multiple linear regression, but
Background characteristics
Of the 5535 ICD recipients invited to participate, 3067 responded for a 55% response rate for all ICD recipients in Sweden. Of these, 2658 had data on the variables used in this analysis (Table 1). There was no way to determine the number of invited individuals who died between the time of implant and the time of data collection. The mean age of the respondents was 65 ± 12 years with a range of 19–94 years of whom 20.6% were female. Time since implantation ranged from one to 23 years with a
Discussion
Our results indicate that greater multi-morbidity burden is associated with lower QOL, which echoes the findings of studies in the general population [14,39,40]. Multi-morbidity affects multiple dimensions of QOL (e.g., physical, psychological, and social). A systematic review of studies for which QOL was the main outcome measure included seven international studies that indicated the negative impact of multi-morbidity on QOL [14]. All of the reported studies noted this relationship,
Conclusions
The ICD is considered as a lifesaving/extending device, yet there are important psychological ramifications with a significant impact on overall QOL and clinical outcomes that should be discussed and considered prior to device implantation, particularly in recipients with multi-morbid conditions. The presence of psychological distress should be monitored and treated in these patients during all phases of device therapy. There is currently an opportunity for improvement in the recognition and
Funding
This work was supported by grants from the Medical Research Council of Southeast Sweden (FORSS).
Declarations of interest
None.
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