Sleep disturbances and psychosocial factors can affect quality-of-life outcomes in patients with implantable cardioverter defibrillators (ICDs), suggests new research presented at the Heart Failure Congress 2015 of the European Society of Cardiology Heart Failure Association.

The cross-sectional study of more than 200 patients, each with an ICD and most with coronary artery disease, showed that the presence of insomnia and/or symptoms of posttraumatic stress disorder (PTSD) significantly decreased acceptance of the device, which was defined as “the psychological accommodation and understanding of the device and its benefits.”

“Patients are telling us that they are very open to receiving information on ways to deal with all of this, especially through bibliography and educational booklets that are specifically targeted. And that’s something we can provide as routine care,” lead author Jonathan Gallagher (Beaumont Hospital, Dublin, Ireland) told heartwire from Medscape.

“It’s important to recognize symptoms that they need to be concerned about, normalize those symptoms, and tell them how they can access care. It just doesn’t do any good to screen if you don’t follow up,” said Gallagher.

ICD Comorbidities

In the poster, the investigators note that past research has shown benefits for patients who had higher levels of ICD acceptance, but an increased risk of mortality in those who had comorbid PTSD.

Gallagher pointed out that ICD patients are also commonly prone to insomnia because of worries that the device will fire at night. “That’s concerning, because insomnia is increasingly being seen as an independent risk factor for cardiac outcomes,” he said.

On the other hand, “patients with higher levels of device acceptance are better able to psychologically accommodate the advantages and disadvantages of having an ICD and experience better health-related quality of life.” But what happens when that acceptance is affected? And how do patients cope with stressors?

“In Ireland, there are virtually no data on psychological adjustment of ICD patients that we can use to inform our services. In the study, we wanted to find out degree of unmet psychological need in our patients here at Beaumont Hospital and how we could restructure our services to meet that need,” reported Gallagher.

A total of 256 ICD patients (82% men; mean age 67.8 years) were enrolled, with ischemic heart disease the most common reason for ICD implantation.

Measures administered to all participants included the Sleep Condition Indicator, the PTSD Checklist, and the Florida Patient Acceptance Survey. In addition, criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) were used to screen for probable insomnia disorder, which was found in 13.2% of the patients.

Poor device acceptance was significantly associated with both sleep quality (P<0.05) and having probable insomnia disorder (P<0.001). In addition, 12.9% of the participants had scores indicating probable PTSD, which was also significantly associated with poor device acceptance (P<0.001) - as was having symptoms of PTSD (P<0.05).

Multiple Modes of Support

Further analysis showed that the most-cited “support preference” from a provided list of resources was a printed informational booklet about ICDs (42.2%), followed by a cardiac nurse specialist (37.1%), and then a family physician (27.5%). Only 11.2% selected an ICD smartphone app as a resource.

Perhaps not surprising, patients older than 60 years were significantly less likely than their younger counterparts to select visits with a cardiac psychologist (P<0.009) or interactions with web-based ICD data (P<0.002), an ICD smartphone app (P<0.001), or an online ICD self-help program (P<0.001) as an "acceptable form of support." The preferences did not differ significantly between the sexes.

"Our findings showed that there are a number of modes of support that patients are open to, and this is an important part of cardiac care,” said Gallagher. “It’s not one-size-fits-all,” he said, adding that clinicians should also consult with a psychologist if PTSD is suspected and should screen for insomnia.

He also recommended examining models proposed by Dr Samuel Sears, who runs the Cardiac Psychology Research Lab at East Carolina University in Greenville, NC, and has written about psychosocial interventions for ICD patients and their families.

“He’s a bit of a trailblazer, and we hope to build toward emulating his models,” said Gallagher. “It’s where a cardiac psychologist is involved in all aspects of cardiac care for these patients. But it all starts with building an effective screening and referral process for patients who are in distress and then enhancing services.”

Tiny Jaarsma (Linköping University, Norrköping, Sweden) included this study in her presentation during the “2015 Highlights” session. “It shows that we just have to follow up with these patients and give them proper education and counseling,” she told attendees. “That’s essential.”

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Gallagher reported no relevant financial relationships

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Deborah Brauser