Transvenous Lead Extraction for Cardiac Implantable Electronic Devices.

This article illustrates the important role that lead extraction plays in the management of patients with cardiac implantable electronic devices. Individualized care of the patient is paramount when considering lead management strategies. The critical care nurse must have a comprehensive understanding of the indications, procedural considerations, and preprocedural and postprocedural care for patients undergoing lead extraction procedures, thereby improving patient safety and maximizing patient outcomes.

Shocktivity: ability and avoidance of daily activity behaviors in ICD patients.

BACKGROUND: Implantable cardioverter defibrillator (ICD) shocks terminate potentially life-threatening arrhythmias and may alter patient behavior. Patients are aware of which activities they have the ability to perform, but they may choose to avoid these behaviors after receiving a shock. This study examined ICD patient ability and avoidance of progressively exertive behaviors. METHODS: ICD patients (N = 443) across the United States were surveyed using an online measure including the 12-item Duke Activity Status Index. RESULTS: As expected, many patients reported being unable to participate in more physically exertive activities such as strenuous athletic exertion (68.8%), sex (35.4%), and running a short distance (49.0%). Avoidance rates were also relatively high, as patients who reported being able to participate in these activities also reported avoiding them (ie, strenuous athletics, 76.1%). Similarly, the majority of patients reported ability to engage in sexual activity (64.6%) but many chose to avoid sexual activity (51.0%). Multiple reasons were reported for avoidance, including fear of shock, fear of heart rate increase, doctor instruction, no desire, and an "other" option. CONCLUSION: Many ICD patients experience behavioral limitations because of both a perceived inability and preference to avoid exertive activities, and possibly a prescription to do so, particularly strenuous athletic exertion. Clinical and research attention to ICD patient activity levels and reasons for avoidance may improve daily functioning and help patients return to preimplant levels of activity.

The Florida Shock Anxiety Scale (FSAS) for patients with implantable cardioverter defibrillators: testing factor structure, reliability, and validity of a previously established measure.

BACKGROUND: The implantable cardioverter defibrillator (ICD) reduces mortality in patients at risk for life-threatening arrhythmias via high energy shock. The Florida Shock Anxiety Scale (FSAS) was developed to measure ICD patient shock-related anxiety. Initial psychometric evaluation revealed good reliability and validity. The purpose of this study was to examine the psychometrics of the FSAS in a large US sample of ICD patients. METHODS: Participants were recruited via e-mail and the survey was completed online. Ultimately, 443 ICD patients (359 male and 421 White) completed the 10-item FSAS. RESULTS: Means for FSAS were comparable to previously published data (M = 15.18, SD = 6.5). Interitem reliability was good (Cronbach's α= 0.89). The FSAS was negatively correlated with single-item measures of emotional well-being (r =-0.378, P < 0.01), sense of security (r =-0.365, P < 0.01), perceived general health (r =-0.185, P < 0.01), and quality of life (r =-0.216, P < .01), demonstrating discriminant validity. Convergent validity was supported through significant correlations with number of shocks (r = 0.464, P < 0.01) and reported disruptiveness of shock (r = 0.484, P < 0.01). Confirmatory factor analysis revealed that a single (second-order) factor model (χ(2) [34] = 75.34, P < 0.05, comparative fit index = 0.98, root mean-square error of approximation = 0.05) had the best fit. CONCLUSIONS: Shock anxiety as a construct can be measured in a reliable and valid method by the FSAS. These nationally representative data suggest that a single score for shock anxiety is an easy to use and appropriate method of assessment.

Quality of life with atrial fibrillation: do the spouses suffer as much as the patients?

BACKGROUND: Atrial fibrillation (AF) can have a significant effect on quality of life (QoL). Other chronic diseases are known to not only affect the patient but to also impact the QoL of persons living with them. Scant data exist on the QoL effect of AF in spouses/significant others (SOs). METHODS: An anonymous survey regarding the perceived effect of AF on QoL was designed and distributed to both patients and spouses/SOs during an educational symposium about living with AF. Both were asked to fill out the survey independently according to how their life was affected by either their AF or their partner's AF. Questions included demographics, perceived impairment of overall QoL on a 5-point scale, as well as effect on subcategories of QoL, namely daily activity, work life, sex life, physical activity, psychological well-being, and social activity. RESULTS: Five hundred and sixty-eight subjects completed the survey of which 411 were AF patients and 129 were spouses/SOs. The perceived effect of AF on overall QoL (N = 527) was similar in patients and spouses (AF patients: mild 42.0%, moderate 26.0%, severe 32.0% vs. spouses: 44.1%, 25.2%, 31.7%; P = 0.917). This result did not change when adjusted for age and gender. There was also no significant difference between patients and spouses in the subcategories of QoL with the exception of the perceived effect on work life, which was greater in patients than spouses (P = 0.041). CONCLUSIONS: AF has a similar perceived impact on the QoL of spouses and patients. QoL improvement strategies for patients with AF should take spouses into account.

Differential effects of statins (pravastatin or simvastatin) on ventricular ectopic complexes: Galpha(i2), a possible molecular marker for ventricular irritability.

Retrospective studies suggest that statins might exert an antiarrhythmic effect on the heart. The mechanism of this effect is unclear. Parasympathetic stimulation of the heart has been shown to protect against ventricular arrhythmias. The goal of this study was to determine the effect of statins on ventricular arrhythmias and its correlation with changes in parasympathetic responsiveness and Galpha(i2) expression. Patients were randomized to pravastatin and simvastatin in a double-blind crossover design. Ventricular arrhythmias were determined by analysis of 24-hour Holter recordings. Spectral RR interval analysis of Holter studies determined peak high-frequency power fraction, which reflects parasympathetic modulation of heart rate. Expression of Galpha(i2), a molecular component of the parasympathetic response pathway, was determined by Western blots of patients' lymphocytes. Pravastatin treatment decreased the incidence of ventricular premature complexes by 22.5 + or - 3.4% (n = 20, p <0.05), couplets, and runs of 3 to 6 beats of nonsustained ventricular tachycardia from 9.8 + or - 2.67 to 3.9 + or - 1.25 events/patient/24 hours (n = 12, p <0.05). Pravastatin increased peak high-frequency fraction by 29.8 + or - 4.3% (n = 33, p <0.001), while Galpha(i2) expression increased by 51.3 + or - 22.5% (n = 21, p <0.05). Effects of simvastatin on ventricular premature complexes and nonsustained ventricular tachycardia were not significant. Relative changes in couplets and nonsustained ventricular tachycardia in pravastatin-treated patients correlated negatively with changes in Galpha(i2) and high-frequency fraction (rho = -0.588 and rho = -0.763, respectively, n = 12, p <0.05). In conclusion, these data suggest that pravastatin might decrease cardiac irritability via an increase in parasympathetic responsiveness and that changes in Galpha(i2) expression might serve as a molecular marker for this effect, which might play a role in the molecular mechanism of the antiarrhythmic effect of statins.

Sudden cardiac arrest prevention pathways and tools.

Evidence-based consensus treatment guidelines are available to assist physicians with management of patients at risk for sudden cardiac arrest (SCA), including patients with heart failure and those after myocardial infarction with left ventricular dysfunction. Although it has been generally presumed that health care providers incorporate cardiovascular treatment guidelines into clinical practice, the actual assimilation of evidence-based strategies and guidelines has been demonstrated to be less than ideal. Studies of heart failure and postmyocardial infarction care show that treatment guidelines are slowly adopted and inconsistently applied, and thus often fail to lead to improvements in patient care and outcomes. These treatment gaps may result in part because evidence-based tools to identify appropriate patients and provide practitioners with useful reminders based on the guidelines have not been widely available. The SCA prevention pathways and tools program is a comprehensive set of pathways and tools to help facilitate optimal patient care for those at increased risk for SCA, including patients with a prior myocardial infarction with left ventricular dysfunction and those with heart failure. Intended for inpatient, outpatient, and transitional care settings, the SCA prevention pathways and tools program supports the recognition and implementation of evidence-based, guideline-recommended care in eligible patients without contraindications. By facilitating best-care practices, the program aims to assist physicians and other health care providers in a meaningful way to improve cardiovascular care and optimize clinical outcomes.

Age-specific differences in women with implantable cardioverter defibrillators: an international multi center study.

BACKGROUND: Common psychological adjustment difficulties have been identified for groups of implantable cardioverter defibrillator patients, such as those who are young (<50 years old), have been shocked, and are female. Specific aspects and concerns, such as fears of death or shock and body image concerns, that increase the chance of distress, have not been examined in different aged female implantable cardioverter defibrillator (ICD) recipients. The aim of the study was to investigate these areas of adjustment across three age groups of women from multiple centers. METHODS: Eighty-eight female ICD patients were recruited at three medical centers: Shands Hospital at the University of Florida, Brigham and Women's Hospital in Boston, and Royal North Shore Hospital in Sydney, Australia. Women completed individual psychological assessment batteries, measuring the constructs of shock anxiety, death anxiety, and body image concerns. Medical record review was conducted for all patients regarding cardiac illnesses and ICD-specific data. RESULTS: Multivariate and univariate analyses of variance revealed that younger women reported significantly higher rates of shock and death anxiety (Pillai's F=3.053, P=0.018, eta2p=0.067) and significantly greater body image concerns (Pillai's F=4.198, P=0.018, eta2p=0.090) than middle- and older-aged women. CONCLUSIONS: Women under the age of 50 appear to be at greater risk for the development of psychosocial distress associated with shock anxiety, death anxiety, and body image. Clinical-based strategies and interventions targeting these types of adjustment difficulties in younger women may allow for improved psychosocial and quality of life outcomes.