Cardiac rehabilitation: Effective yet underutilized in patients with cardiovascular disease.

Cardiac rehabilitation is a comprehensive program that treats patients with multiple cardiac conditions including post-myocardial infarction, stable angina, post-coronary artery bypass surgery, chronic heart failure, and peripheral vascular disease with structured exercise, and nutrition and risk factor counseling. It is an effective tool that has been shown to improve not only quality of life but also reduce adverse cardiac events, including death. While the value of cardiac rehabilitation is supported by a large body of evidence and its recommendation by the American Heart Association/American College of Cardiology it is significantly underutilized due to both patient and systemic factors. Continued efforts should be made to remove the obstacles to make cardiac rehabilitation available to all those who qualify.

Associations between pain, objective sleep efficiency and cognition in patients with implantable cardioverter defibrillators.

INTRODUCTION: Patients with implantable cardioverter defibrillators (ICDs) frequently experience sleep disruption. Prior work shows associations between objective (actigraphic) sleep and cognition in these patients, but whether pain affects associations between measures of sleep fragmentation (eg, sleep efficiency, SE) and cognition is unknown. The present study examined independent and interactive associations between objective SE and pain on cognitive performance in patients with ICDs. METHODS: A total of 37 patients with ICDs (Mage = 60.0, SD = 12.4) and self-reported sleep disturbance completed 14 days of actigraphy. Average SE was computed [(average total sleep time/average time in bed) × 100%]. Patients completed the Short Form 36 Health Survey pain section, and computerized tasks measuring executive functioning (letter series, N-Back task), sustained attention/processing speed (symbol digit modalities test, SDMT), and simple reaction time. Multiple linear regressions examined whether SE independently predicted or interacted with pain ratings to predict cognitive performance. RESULTS: SE interacted with pain to predict SDMT performance, accounting for 12% unique variance. In patients reporting worse pain, higher SE was associated with better SDMT performance. Similar patterns of association on SDMT were not observed in patients with average or low pain. SE and pain ratings did not independently predict SDMT performance. Performance on other cognitive tasks was not associated with any predictors. CONCLUSION: Better sleep efficiency may play an important role in improving sustained attention/processing speed in patients with ICDs and perceived severe pain. Future research should examine whether interventions aimed at improving sleep fragmentation provide benefit to lower order cognition, particularly in patients with worse pain.

Minimally invasive thoracoscopic surgery is an effective approach for treating inappropriate sinus tachycardia.

INTRODUCTION: Inappropriate sinus tachycardia (IST) is characterized by increased heart rate out of proportion to normal physiologic demand. IST ablation is challenging for the electrophysiology community due to the epicardial location of the sinus node and the risk of phrenic nerve (PN) injury during catheter ablation. In this study, we investigated the safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of IST. METHODS: Patients with IST who failed medical therapy or endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identify the earliest activation site and any possible migration of earliest activation along the lateral right atrium. The PN in each patient was protected by a pericardial retraction suture. RESULTS: From 1 January 2000 to 15 June 2018, 10 patients (eight females and two males) underwent minimally invasive thoracoscopic IST ablation. Mean age of the patients was 36.7 ± 12.5 years. Mean baseline sinus rate was 113.8 ± 21.8 beats per minute. After surgery, the mean heart rate significantly decreased to 79.8 ± 8.2 at postoperative day 1 and to 75.8 ± 8.1 at day 30 (both P < .001). No in-hospital death, stroke, or PN injury occurred. One patient required reintubation, one patient developed postoperative pericarditis, and another patient had a pulmonary embolus. Median follow-up was 6 months (range, 1-50). Freedom from reintervention was 88% at 6 months. CONCLUSION: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after surgery is required.

Cognitive performance in patients with implantable cardioverter defibrillators: Associations with objective sleep duration, age and anxiety.

Sleep disturbance and anxiety are highly prevalent in patients with implantable cardiac defibrillators (ICDs). There is limited research, however, on the associations between cognitive performance and sleep parameters, age and anxiety. Forty-one patients with ICDs and self-reported sleep disturbance completed 14 days of actigraphy (Mage  = 60.3, SD = 12.3) measuring total sleep time (TST), and a computerized cognitive test battery measuring processing speed and attention (i.e. simple reaction time and symbol digit modality task [SDMT]) and executive function (i.e. flanker task, letter series task and N-back task). Multiple regressions determined whether independent effects of TST, age and anxiety, as well as interactive effects of TST and age, predicted cognitive performance. TST predicted performance on two tasks of executive function (i.e. letter series and N-back task), as well as an attentional vigilance and processing speed task (i.e. SDMT), and this did not depend on patient age. On letter series, N-back and SDMT, longer TST predicted better performance. Increasing age was a predictor of worse performance on SDMT and flanker tasks. No other predictors were associated with task performance. Results show that sleep duration, not anxiety, may be an important predictor of higher-order cognitive functioning and lower-order tasks measuring processing speed and attention in ICD patients, with longer sleep duration showing greater benefit for performance.

Iatrogenic Ventricular Fibrillation after Direct-Current Cardioversion of Preexcited Atrial Fibrillation Caused by Inadvertent T-Wave Synchronization.

Direct-current cardioversion is an important means of managing arrhythmias. During treatment, carefully synchronizing energy delivery to the QRS complex is necessary to avoid ventricular fibrillation caused by a shock during the vulnerable period of ventricular repolarization, that is, a shock on the T wave. The presence of an accessory pathway and ventricular preexcitation can lead to difficulty in distinguishing the QRS complex from the T wave because of bizarre, wide, irregular QRS complexes and prominent repolarization. We present the cases of 2 patients who had iatrogenic ventricular fibrillation from inappropriate T-wave synchronization during direct-current cardioversion of preexcited atrial fibrillation. Our experience shows that rapidly recognizing the iatrogenic cause of VF and immediate treatment with unsynchronized defibrillation can prevent adverse clinical outcomes.

Patients With Implantable Cardioverter Defibrillators on Social Media Report More Shock Anxiety Than Clinic Patients: Results From an Online Survey.

BACKGROUND: Coping with heart disease and the potential for implantable cardioverter defibrillator (ICD) shocks challenges the psychological adjustment of patients with ICDs. Social media use may be used to seek education and support from others. OBJECTIVE: The aim of this study was to examine the content of information sought online and whether a social media sample of patients with ICDs report more device-specific anxiety than clinic-based normative samples. METHODS: A total of 196 participants were recruited via social media messages and invited to complete an online survey. RESULTS: It was found that the information most often sought by online users (62.4%, 123/196) involved both emotional support (eg, gaining emotional support from other patients with ICDs) and technical information (52.6%, 103/196) (eg, dealing with magnetic interference). The online sample reported more shock anxiety than a typical clinical sample with mean values of 22.75 (SD 10.06) and 15.18 (SD 6.50), respectively (P<.001). CONCLUSIONS: Collectively, these results suggest that patients with ICDs that are online are seeking emotional information and support, and that they report increased shock anxiety relative to typical clinic-based patients. Future research should examine how online information and clinical-based information form a composite understanding and adjustment for patients ICDs.

Sleep, Psychosocial Functioning, and Device-Specific Adjustment in Patients with Implantable Cardioverter Defibrillators (ICDs).

Rates of sleep disorders and associated adjustment were examined in patients with implantable cardioverter defibrillators (ICDs; n = 42; Mage = 61.57, SD = 12.60). One night of ambulatory polysomnography, 14 days of sleep diaries, and questionnaires (mood, sleepiness, fatigue, device acceptance) were administered. Controlling for ischemia, MANCOVA examined adjustment by sleep diagnosis. Apnea was most common (28.6%), followed by Insomnia (16.7%) and Comorbid Insomnia/Apnea (11.9%). Patients with insomnia reported poorer mood, greater sleepiness, and lower device acceptance than good sleepers; they also demonstrated poorer mood and less ICD device acceptance than patients with sleep apnea. Patients with comorbid insomnia/apnea also exhibited poorer mood and less ICD device acceptance than good sleepers; however, comorbid patients did not significantly differ from insomnia or apnea patients on any measure. Those with disordered sleep (regardless of type) reported greater fatigue than good sleepers. Assessment (and treatment) of difficulties with sleep, mood, fatigue, and device acceptance may be important for the comprehensive clinical management of ICD patients. Further research appears warranted.

Implantation of a cardiac resynchronization therapy defibrillator in a patient with bilateral deep brain stimulator: feasibility and technique.

Uncommonly, a patient with a NeuroStimulator Device (NSD) for a neurologic indication requires a cardiovascular implantable electronic device (CIED) for a cardiac indication. Typically in those with a unilateral pectoral NSD, the contralateral pectoral space is used for CIED implantation; however, in very rare occasions the patient has bilateral pectoral NSDs which makes subsequent implantation of a CIED challenging both because of placement and device interaction. Herein, we introduce the case of a 68-year-old gentleman with bilateral pectoral deep brain stimulators for Parkinsonism who received cardiac resynchronization therapy-defibrillator (CRT-D) for advanced heart failure. The CRT-D generator was implanted in the abdomen and the CRT-D leads were placed through a minimally invasive epicardial approach. Both devices were tested without any evidence of device interaction.

Phantom shocks unmasked: clinical data and proposed mechanism of memory reactivation of past traumatic shocks in patients with implantable cardioverter defibrillators.

BACKGROUND: Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor. METHODS: A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks. RESULTS: Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms. CONCLUSIONS: Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.

Comparison of actigraphic and subjective measures of sleep in implantable cardioverter defibrillator and coronary artery disease patients.

BACKGROUND: Cardiac patients frequently have insomnia symptoms that may pose risk for future cardiac events. Poor sleep relates to hyperarousal, anxiety and depression, and the incidence of hypertension and myocardial infarction. HYPOTHESIS: The authors hypothesized that implantable cardioverter defibrillator (ICD) patients would have poorer sleep than coronary artery disease (CAD) patients related to hypervigilance for device functioning and shock discharge. METHODS: Authors investigated sleep efficiency and sleep latency in a sample of 60 patients (n = 30 CAD and n = 30 ICD) without obstructive sleep apnea at the University of Florida & Shands Hospital. For 14 days, participants completed a sleep diary. Additionally, half of the total sample also used actigraphy to objectively measure their sleep. Measures of somatic hypervigilance and psychosocial distress were administered. RESULTS: Using actigraphy, mean sleep efficiency was poorer (69.76%) in CAD patients compared with ICD patients (82.80%). This difference was highly significant, F1,27 = 16.840, P < 0.001. CAD patients also had shorter mean total sleep times per sleep diaries compared with ICD patients (336.19 minutes or 5.60 hours, 430.65 minutes or 7.18 hours, respectively), F1,27 = 15.908, P < 0.001. CONCLUSIONS: The finding that ICD patients slept more efficiently than CAD patients is surprising given that CAD patients had higher ejection fractions and no concerns about ICD shocks. This difference cannot be accounted for by differences in hypervigilance, depression, anxiety, or physical activity. Results suggest that CAD patients may have more sleep problems and may warrant increased research attention.