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Background: Idiopathic ventricular fibrillation (iVF) is diagnosed in cardiac arrest survivors without an identifiable cause. Data regarding the health-related quality of life (HRQoL) in iVF patients are lacking. The purpose of this study was to investigate the HRQoL of iVF patients and to compare it to patients with an implantable cardioverter defibrillator (ICD) diagnosed with an underlying disease and healthy subjects., Methods: In 61 iVF patients with an ICD (iVF-ICD) and 59 ICD patients with a diagnosis (diagnosis-ICD), HRQoL was assessed using the 12-item Short-Form Health Survey (SF-12), the EuroQoL-5 dimensions (EQ-5D), the 9-item Patient Health Questionnaire, and the ICD Patient Concerns (ICDC) Questionnaire. In addition, 860 healthy subjects completed the SF-12., Results: IVF-ICD showed similar SF-12 physical summary scores compared with diagnosis-ICD patients (50.8 [interquartile range (IQR) = 42.1-53.9] vs 54.1 [IQR = 46.5-58.3]; P = 0.080) and healthy subjects (51.8 [IQR = 45.9-54.1]; P = 0.691). The mental summary score was impaired in iVF-ICD patients compared with diagnosis-ICD patients (45.9 [IQR = 40.7-49.4] vs 54.6 [IQR = 46.0-57.9]; P < 0.001) and healthy subjects (47.7 [IQR = 43.0-50.4]; P = 0.027). Scores on all five EQ-5D domains were similar between iVF-ICD patients and diagnosis-ICD patients, as well as symptoms of severe depression (19% vs 12%; P = 0.101). ICD concerns were similar between iVF-ICD and diagnosis-ICD patients (ICDC-scores 2 vs 2; P = 0.494)., Conclusions: Data suggest that there is a reduced mental HRQoL in patients with iVF compared to other cardiac arrest survivors. Screening and treatment of psychological distress should therefore be considered in iVF patients., (© 2017 Wiley Periodicals, Inc.)

Objective: To examine the assumption that depression leads to recurrent cardiac events and death in those with heart disease., Methods: Consideration of alternative perspectives and discussion of the literature., Results: It is not clear from studies like MIND-IT, ENRICHD or SADHART whether depression treatment improves cardiac outcomes. In these studies, recurrent cardiac events and death were recorded 6months or more after study entry, but shorter-term cardiac outcomes (e.g., stabilization of plaque prone to rupture and thrombosis or changes in areas of myocardium prone to life-threatening arrhythmia) were not assessed. Although the prevailing view is that shorter-term improvement in depression is necessary to improve cardiovascular outcomes, the possibility that shorter-term improvement in cardiac status might result in reduced symptoms of depression has not been examined. If correct, this possibility might explain why studies have shown that patients whose depression improves also exhibit improved cardiovascular outcomes and lower mortality, even though randomization to the depression intervention in these studies had no effect., Conclusion: It is not clear whether improving depression comes first and reduced cardiac events follows or whether patients whose cardiac status improves also exhibit improvement in depression. Which is the chicken and which the egg is more than just a philosophical question, since it may affect the direction of future research in this field, and even how we approach the care of patients with heart disease and depression., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: A subgroup of patients with an implantable cardioverter defibrillator (ICD) experiences anxiety after device implantation. The purpose of the present study was to evaluate whether anxiety is predictive of ventricular arrhythmias and all-cause mortality 1 year post ICD implantation., Methods: A total of 1012 patients completed the state version of the State-Trait Anxiety Inventory at baseline. The end points were ventricular arrhythmias and mortality the first year after ICD implantation., Results: Within the first year after ICD implantation, 19% of patients experienced a ventricular arrhythmia, and 4% died. Anxiety was associated with an increased risk of ventricular arrhythmias (hazard ratio [HR] = 1.017; 95% confidence interval [CI] = 1.005-1.028; p = .005) and mortality (HR = 1.038; 95% CI = 1.014-1.063; p = .002) in adjusted analysis. Patients with anxiety (highest tertile) had a 1.9 increased risk for ventricular arrhythmias (95% CI = 1.329-2.753; p =.001) and a 2.9 increased risk for mortality (95% CI = 1.269-6.677; p = .01) compared with patients with low anxiety (lowest tertile). Among 257 patients with cardiac resynchronization therapy, anxiety was associated with mortality (HR = 5.381; 95% CI = 1.254-23.092; p = .02) after adjusting for demographic and clinical covariates., Conclusions: Anxiety was associated with an increased risk of ventricular arrhythmias and mortality 1 year after ICD implantation, independent of demographic and clinical covariates. Monitoring and treatment of anxiety may be warranted in a selected subgroup of high-risk patients with an ICD.

Background: Ventricular arrhythmia is a significant cause of sudden death. Implantable cardioverter-defibrillators (ICDs) offer at-risk patients a prophylactic treatment option. This prophylaxis is largely responsible for growth in utilization of ICDs. Identification of factors that may impact device-specific quality of life (QOL) is warranted. The influence of preimplant patient variables on postimplant device-specific QOL is unknown. The study aimed to determine whether preimplant psychosocial, generic health-related quality of life (HRQOL), personality disposition, or demographic factors predicted early postimplant device-specific QOL., Methods: A prospective cohort study design was employed in 70 adults receiving an ICD for primary prevention. Preimplant, we measured generic HRQOL, personality disposition, depressive symptoms, age, and sex. The primary outcome was 3-month ICD device-specific QOL as measured by the Florida Patient Acceptance Scale (FPAS). We applied hierarchical multivariate regression analysis., Results: Mean age was 64.8 ± 9.4 years; 12.9% were women. Most had ischemic heart disease (77%) and a heart failure history (54.3%). Preimplant prevalence of elevated depressive symptoms was 30%. Three months post implant, the mean adjusted FPAS score was 76.8 ± 12.98. Of the variance in FPAS scores, 37% was explained by the independent variables. Younger age and poor preimplant mental HRQOL contributed most to lower FPAS scores., Conclusions: Patient support and psychosocial interventions should target younger ICD candidates and those reporting poor preimplant mental HRQOL; these patients may be at risk for poor postimplant device-specific QOL., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Eating disorders are not infrequent in adolescents, and associated cardiac arrhythmias (CA) are well described in these patients. However, CA in adult eating disorders have been reported only rarely. We report a case of ventricular fibrillation in a patient presenting with fatigue and a recent history of vomiting.

Emotional stress facilitates the occurrence of cardiac arrhythmias including sudden cardiac death. The prevalence of anxiety and depression is increased in cardiac patients as compared to the normal population. The risk of cardiovascular mortality is enhanced in patients suffering from depression. Comorbid anxiety disorders worsen the course of cardiac arrhythmias. Disturbance of neurocardiac regulation with predominance of the sympathetic tone is hypothesized to be causative for this. The emotional reaction to cardiac arrhythmias is differing to a large extent between individuals. Emotional stress may result from coping with treatment of cardiac arrhythmias. Emotional stress and cardiac arrhythmias may influence each other in the sense of a vicious circle. Somatoform cardiac arrhythmias are predominantly of psychogenic origin. Instrumental measures and frequent contacts between physicians and patients may facilitate disease chronification. The present review is dealing with the multifaceted relationships between cardiac arrhythmias and emotional stress. The underlying mechanisms and corresponding treatment modalities are discussed.

Background: The testing of the implantable cardioverter-defibrillator (ICD), through the induction of repeated episodes of ventricular fibrillation, has been associated with disturbances in cerebral activity and increased levels of cytoplasmic enzymes. However, the neuropsychological outcomes of cerebral changes and their quality-of-life implications are unknown., Methods and Results: Fifty-two ICD recipients completed standardized validated neuropsychological tests 1 to 3 days before ICD surgery and then 6 weeks, 6 months, and 12 months after surgery. They also completed psychometric tests measuring anxiety, depression, and quality of life. Between 31% and 39% of patients showed a significant neuropsychological impairment from their baseline function 6 weeks, 6 months, and 12 months after surgery. Ten percent of patients had late-onset deficits at 12 months only. Frequent areas of impairment were auditory and visual memory and attention. Neuropsychological impairment was not related to mood or quality of life at follow-up, although anxiety and depression predicted reduced quality of life., Conclusions: ICD implantation is associated with neuropsychological impairment that dissipates for the majority of recipients after 12 months. Short-term memory function and attention are particularly vulnerable to changes in oxygen during ICD testing. Although anxiety and depression are prevalent, there is little evidence for the direct impact of mood on cognition, and deficits appear not to be associated with reduced quality of life. These results provide evidence for longitudinal outcomes of ICD surgery and have implications for patient rehabilitation and adjustment.

Objectives: This study sought to determine whether T-wave alternans (TWA) induced by anger in a laboratory setting predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs)., Background: Anger can precipitate spontaneous ventricular tachycardia/ventricular fibrillation and induce TWA. Whether anger-induced TWA predicts future arrhythmias is unknown., Methods: Sixty-two patients with ICDs underwent ambulatory electrocardiography during a mental stress protocol, 3 months after the ICD was implanted. T-wave alternans was analyzed using time-domain methods. After a > or =1 year follow-up, ICD stored data was reviewed to determine incidence of ICD-terminated ventricular tachycardia/ventricular fibrillation., Results: Patients with ICD-terminated arrhythmias during follow-up (n = 10) had higher TWA induced by anger, 13.2 microV (interquartile range [IQR] 9.3 to 16 microV), compared with those patients without future ventricular arrhythmias, 9.3 microV (IQR 7.5 to 11.5 microV, p < 0.01). Patients in the highest quartile of anger-induced TWA (>11.9 microV, n = 15) were more likely to experience arrhythmias by 1 year than those in the lower quartiles (33% vs. 4%) and during extended follow-up (40% vs. 9%, p < 0.01 for both). In multivariable regression controlling for ejection fraction, prior clinical arrhythmia, and wide QRS, anger-induced TWA remained a significant predictor of arrhythmia, with likelihood in the top quartile 10.8 times that of other patients (95% confidence interval: 1.6 to 113, p < 0.05)., Conclusions: Anger-induced TWA predicts future ventricular arrhythmias in patients with ICDs, suggesting that emotion-induced repolarization instability may be 1 mechanism linking stress and sudden death. Whether there is a clinical role for anger-induced TWA testing requires further study.

During implantable cardioverter-defibrillator (ICD) implantation, ventricular defibrillation testing (DFT) is considered a standard procedure. This procedure often requires multiple ventricular fibrillation (VF) inductions. These repeated short episodes of circulatory arrest with global cerebral ischemia may cause neurological damage. In the present study, patients undergoing initial ICD implantation and limited induction of VF for defibrillation safety margin testing were evaluated for pre- and postoperative cognitive and neurologic functions. In addition, the serum neuron specific enolase (NSE) level, which is a biochemical marker of cerebral injury, was evaluated. The study was performed on 16 patients undergoing initial elective transvenous insertion of an ICD. A neurologic examination and cognitive assessment tests were performed 24 to 48 hours before and after ICD. NSE was determined before (NSE 1) and at the end of the surgery (NSE 2), as well as 2 hours (NSE 3), 24 hours (NSE 4), and 48 hours (NSE 5) after implantation. A total of 29 internal shocks (average, 1.8 +/- 0.4) with energy ranging from 14 to 41 J (mean, 20 +/- 5; median, 20 J ) were delivered in the ICD group patients. In one patient, 3 external (50, 200 and 360 J) shocks were required for fast VT induced during ICD lead positioning. The mean duration of VF was 10 +/- 4 seconds and the mean cumulative time in VF was 16 +/- 5 seconds. The mean recovery time between VFs was 5.3 +/- 0.6 minutes. NSE levels were not different from the baseline at any time point in the patients of the group that completed the 48-hour observation period (P > 0.05). The patients did not report any new neurological symptoms after ICD implantation, and repeat examination after the procedure showed no abnormal findings other than those detected in the previous one. There were no statistically significant differences between the preoperative and postoperative scores obtained in the cognitive assessment. Single or two VF inductions and the brief arrest of cerebral circulation during ICD implantation are not associated with permanent neurological injury. However, further studies are needed to confirm this finding.

Objectives: This study examined the risk of implantable cardioverter-defibrillator (ICD) shocks for ventricular tachycardia (VT) or ventricular fibrillation (VF) associated with driving., Background: Concerns regarding VT/VF occurring during driving are the basis for driving restrictions in ICD patients; however, limited data are available to inform recommendations., Methods: This study used a prospective nested case-crossover design to compare the risk of ICD shock for VT/VF both during and up to 60 min after an episode of driving as compared with that during other activities among 1,188 ICD patients enrolled in the TOVA (Triggers of Ventricular Arrhythmia) study., Results: Over a median follow-up of 562 days, there were 193 ICD shocks for VT/VF with data on exposure to driving before ICD shock. The absolute risk of ICD shock for VT/VF within 1 h of driving was estimated to be 1 episode per 25,116 person-hours spent driving. The ICD shocks for VT/VF were twice as likely to occur within 1 h of driving a car as compared with other times (relative risk [RR] 2.24, 95% confidence interval [CI] 1.57 to 3.18). This risk was specific for shocks for VT/VF and occurred primarily during the 30-min period after driving (RR 4.46, 95% CI 2.92 to 6.82) rather than during the driving episode itself (RR 1.05, 95% CI 0.48 to 2.30)., Conclusions: Although the risk of ICD shock for VT/VF was transiently increased in the 30-min period after driving, the risk was not elevated during driving and the absolute risk was low. These data provide reassurance that driving by ICD patients should not translate into an important rate of personal or public injury.

We report a comprehensive investigation of the anterograde memory functions of two patients with memory impairments (RH and JC). RH had neuroradiological evidence of apparently selective right-sided hippocampal damage and an intact cognitive profile apart from selective memory impairments. JC, had neuroradiological evidence of bilateral hippocampal damage following anoxia due to cardiac arrest. He had anomic and "executive" difficulties in addition to a global amnesia, suggesting atrophy extending beyond hippocampal regions. Their performance is compared with that of a previously reported hippocampal amnesic patient who showed preserved recollection and familiarity for faces in the context of severe verbal and topographical memory impairment [VC; Cipolotti, L., Bird, C., Good, T., Macmanus, D., Rudge, P., & Shallice, T. (2006). Recollection and familiarity in dense hippocampal amnesia: A case study. Neuropsychologia, 44, 489-506.] The patients were administered experimental tests using verbal (words) and two types of non-verbal materials (faces and buildings). Receiver operating characteristic analyses were used to estimate the contribution of recollection and familiarity to recognition performance on the experimental tests. RH had preserved verbal recognition memory. Interestingly, her face recognition memory was also spared, whilst topographical recognition memory was impaired. JC was impaired for all types of verbal and non-verbal materials. In both patients, deficits in recollection were invariably associated with deficits in familiarity. JC's data demonstrate the need for a comprehensive cognitive investigation in patients with apparently selective hippocampal damage following anoxia. The data from RH suggest that the right hippocampus is necessary for recollection and familiarity for topographical materials, whilst the left hippocampus is sufficient to underpin these processes for at least some types of verbal materials. Face recognition memory may be adequately subserved by areas outside of the hippocampus.

Objective: Findings of an association between phobic anxiety and elevated risks of sudden cardiac death suggest that phobic anxiety may be related to increased risk of ventricular arrhythmias. The purpose of this study was to examine whether phobic anxiety is associated with ventricular arrhythmias in patients with documented coronary artery disease (CAD)., Methods: Phobic anxiety level was measured using the Crown-Crisp phobic anxiety scale in 940 patients (660 men, 280 women) hospitalized for diagnostic cardiac catheterization between April 1999 and June 2002. Depressive symptomatology was assessed using the Beck Depression Inventory. Patients were followed for a median follow-up period of 3 years, and the occurrence of ventricular arrhythmias was determined through review of medical records., Results: Ventricular arrhythmias occurred in 97 patients and were significantly related to higher phobic anxiety after statistical adjustment for established medical and demographic determinants of arrhythmias (odds ratio = 1.40; p = .012). Depressive symptomatology was significantly correlated with phobic anxiety (r = 0.44, p < .001) and was also related to ventricular arrhythmias (odds ratio = 1.40; p = .006). The composite of depression and phobic anxiety predicted ventricular arrhythmias with a larger effect size than either depression or phobic anxiety score alone (odds ratio = 1.6, 95% confidence interval, 1.2-2.1, p = .002)., Conclusions: Both phobic anxiety and depressive symptomatology predict ventricular arrhythmias in patients with CAD and may share a common factor predictive of ventricular arrhythmias.

Objective: Emotional stress is well established as a trigger of sudden death in the context of coronary heart disease (CHD), but its role in patients experiencing cardiac arrest with apparently normal hearts is unknown. This study sought to determine the role of psychosocial stress as a precipitant of cardiac arrest in patients with apparently normal hearts, so-called idiopathic ventricular fibrillation (IVF)., Methods: We interviewed 25 IVF survivors (12 men, 13 women) and 25 matched comparison patients regarding life events during the 6 months and 24 hours preceding the cardiac event. The comparison group consisted of patients with an acute myocardial infarction or angina pectoris requiring angioplasty but without cardiac arrest. Judges independently rated written summaries of these interviews for psychosocial stress at each time point on a three-point scale (low, moderate, severe)., Results: During the 6 months before the cardiac event, 20 patients sustaining IVF had severe/moderate stress and five had low stress, whereas 10 comparison patients had severe/moderate stress and 15 had low stress (Fisher exact p = .008). During the preceding 24 hours, nine patients with IVF had severe/moderate stress and 16 had low stress, whereas two comparison patients had severe/moderate stress and 22 had low stress (Fisher exact p = .04) (one silent myocardial infarction could not be precisely dated)., Conclusion: These data suggest that psychosocial stress is playing a role in otherwise unexplained cardiac arrest.

Objectives: We sought to examine the relationship between symptoms of depression and shock-treated ventricular arrhythmias among implantable cardioverter-defibrillator (ICD) patients., Background: Depression predicts mortality in patients with coronary artery disease (CAD), but whether this is via an increased risk of fatal ventricular arrhythmias is unclear., Methods: We prospectively analyzed data on symptoms of depression and risk of ventricular arrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]) resulting in ICD discharge in the Triggers of Ventricular Arrhythmias (TOVA) study. Symptoms were assessed by the Center for Epidemiologic Studies-Depression (CES-D) scale. Scores of 16 to 26 and > or =27 represented mild and moderate/severe depression, respectively. The Cox and Anderson-Gill proportional hazards models were used to test for associations among all patients and patients with CAD., Results: Among 645 patients with baseline assessments, 90 (14%) were mildly depressed and 25 (3.9%) were moderately to severely depressed. Moderate/severe depression was associated with time to first shock for VT/VF (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.1 to 9.9) and all shocks for VT/VF including recurrent episodes (HR 3.2, 95% CI 1.2 to 8.6). Among the 476 CAD patients, the association with time to first shock (HR 6.4, 95% CI 1.9 to 21.1) and all shocks (HR 8.3, 95% CI 2.9 to 23.3) remained. The risk of shock for VT/VF was associated with depression severity in the total population (p for trend = 0.02) and among patients with CAD (p < 0.01), even after controlling for multiple confounders., Conclusions: More severe symptoms of depression predict shocks for VT/VF among ICD patients. The elevated risk of VT/VF among patients with CAD and depression suggests that arrhythmia may contribute significantly to total mortality in this subgroup.

Implantable cardioverter defibrillators (ICDs) are being used for primary and secondary prevention of life-threatening cardiac arrhythmias, and evidence suggests that increased use is likely in the future. ICD storm, the delivery of two or more shocks within 24 hours, occurs in 10% to 20% of patients who have ICDs and can have long-lasting psychological and physical consequences. An understanding of the factors associated with ICD storm, relevant assessment, and patient and family teaching and counseling can help clinicians to better meet the needs of patients who have experienced ICD storm.

Since its approval in 1985, the implantable cardioverter-defibrillator (ICD) has supplanted antiarrhythmic drugs as the standard of care for patients with potentially lethal ventricular arrhythmias. The increased popularity of ICDs stems primarily from their safety and tolerability compared with commonly used medications notorious for adverse drug reactions. As ICD indications have broadened, the number of implantations has increased substantially, and more attention has been directed to sequelae of implantation, particularly after ICD firing. Although scant, studies of quality of life and psychiatric symptoms in patients with ICDs consistently report assorted psychiatric disturbances affecting up to 87% of recipients. Depression and anxiety predominate: up to 38% of patients experience symptoms that meet diagnostic criteria for an anxiety disorder. Psychological theories such as the classic conditioning model, learned helplessness model, and cognitive appraisal model have been invoked to conceptualize these new-onset ICD-induced anxiety disorders. Small trials of psychosocial interventions, including support groups and cognitive behavioral therapy, have had mixed results. Little is known about preexisting anxiety disorders in ICD recipients, particularly which premorbid features predict a worse prognosis, other than suggestions that younger patients and those receiving multiple shocks are at greater risk. Prospective studies of the psychopathology of patients with ICDs, both before and after implantation, are warranted.

The clinical success of the implantable cardioverter defibrillator (ICD) in reducing mortality suggests that more women will be receiving ICDs in the future. The impact of ICD therapy in women is unique in western societies; the ICDs scar and lump in the pectoral area can lead to body image concerns due to the emphasis on women's physical attractiveness. Social support and roles are challenged because women's reaction to stress has been characterized by a "tend and befriend" response, involving cultivating and utilizing social networks, rather than the "fight or flight" response more typical of men. In addition, a woman's identity as a caretaker and caregiver can be threatened by the actual and perceived activity limitations imposed by the ICD or the underlying heart condition. Finally, reproductive and sexual health are important issues, as 25 to 50% of patients with ICDs report concerns in this area, but also report discomfort in discussing these concerns with their health care providers. The purpose of the present paper is to review the relevant literature and to identify the unique impact of the psychosocial issues of body image, social support and roles, and sexual development and reproductive functioning for women with ICDs across the lifespan. In the absence of complete empirical research data on the impact of these concerns, hypotheses to test in future research are offered.

Purpose: Clinical trials with the implantable cardioverter defibrillator (ICD) have demonstrated desirable outcomes in terms of mortality and morbidity among patients with potentially lethal arrhythmias. This study examined the "resilience factors" of positive health expectations and global optimism prospectively using the general quality-of-life (QOL) scores of newly implanted ICD patients., Methods: The study enrolled 88 newly implanted ICD patients (mean age, 65.3 +/- 13.2 years; 83% male; 92% white) assessed 8 and 14 months after ICD implantation. A series of 2 x 2 factorial multivariate analyses of covariance were performed to examine the differences between baseline low versus high positive health expectations and baseline low versus high optimism in short- and long-term general QOL scores., Results: After control was used for ejection fraction (mean, 31%), the patients with baseline high positive health expectations reported better general health at a long-term follow-up assessment (P = .002). The patients with high optimism reported better mental health and social functioning at a short-term follow-up assessment (P =. 056), and this finding approached significance at a long-term follow-up assessment (P = .061)., Conclusions: Positive health expectations and optimism are differentially related to various components of QOL. Collectively, these two resilience factors may be targeted in future studies of interventions to improve QOL for ICD patients.

Depression is an important public health problem and is considered to be an independent risk factor for coronary artery disease. The pathophysiological mechanisms that link depression with adverse cardiovascular events (e.g., myocardial ischemia, myocardial infarction, and sudden death) are not well established. It is possible that an increased susceptibility to life-threatening cardiac arrhythmias in depressed patients influences the risk of morbidity and mortality in coronary artery disease. This idea was tested with the use of an experimental model of depression that was developed to induce anhedonia, the reduced responsiveness to pleasurable stimuli observed in human depressed patients. Rats exposed to 4 wk of chronic mild stress (e.g., paired housing, strobe light, and white noise) displayed anhedonia, which was operationally defined by the reduced intake of a palatable sucrose solution relative to an established baseline and to control animals. Furthermore, compared with control rats, the anhedonic rats showed increased basal heart rate and decreased heart rate variability. In response to an intravenously infused chemical challenge, aconitine, anhedonic rats exhibited an increased vulnerability to ventricular arrhythmias, as indicated by a reduced threshold for premature ventricular complexes, salvos, and ventricular tachycardia. These findings suggest that the presence of depressive symptoms is associated with a lower threshold for ventricular arrhythmias, which may contribute to the increased risk for adverse cardiovascular events in patients with depression.

We report on a 61-year-old patient with an implanted defibrillator due to malignant arrhythmia after myocardial infarction. After several years of appropriate function, the patient suffered a cluster of 16 shocks due to a defect in the defibrillator. Soon the patient developed a panic disorder with agoraphobia which was successfully treated with cognitive-behavioral therapy. Possible cognitive-behavioral mechanisms of panic disorder and special issues of behavioral therapy of patients with serious organic diseases are discussed.

Background: There are few data from community-based evaluations of outcomes after a life-threatening ventricular arrhythmia (LTVA). We evaluated patients' quality of life (QOL) and medical costs after hospitalization and treatment for their first episode of an LTVA., Methods: We prospectively evaluated QOL by use of the Duke Activity Status Index (DASI), Medical Outcomes Study SF-36 mental health and vitality scales, the Cardiac Arrhythmia Suppression Trial (CAST) symptom scale, and resource use in patients discharged after a first episode of an LTVA in a managed care population of 2.4 million members., Results: We enrolled 264 subjects with new cases of LTVA. Although functional status initially decreased compared with self-reports of pre-event functional status, both functional status and symptom levels improved significantly during the study period. These improvements were greater in patients receiving an implantable cardioverter defibrillator (ICD) than in patients receiving amiodarone. Ratings of mental health and vitality were not significantly different between the treatment groups and did not change significantly during follow-up. The total 2-year medical costs were higher for patients receiving an ICD than for patients receiving amiodarone, despite lower costs during the follow-up period for the patients receiving an ICD., Conclusions: New onset of an LTVA has a substantial negative initial impact on QOL. With therapy, most patients have improvements in their QOL and symptom level, possibly more so after treatment with an ICD. The costs of treating these patients are very high.

Objectives: Automated external defibrillators (AEDs) provide an opportunity to improve survival in out-of-hospital, ventricular fibrillation (VF) cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. The potential role of emergency dispatchers in the layperson use of AEDs is uncertain. This study was performed to examine whether dispatcher telephone assistance affected AED skill performance during a simulated VF cardiac arrest among a cohort of older adults. The hypothesis was that dispatcher assistance would increase the proportion who were able to correctly deliver a shock, but might require additional time., Methods: One hundred fifty community-dwelling persons aged 58-84 years were recruited from eight senior centers in King County, Washington. All participants had received AED training approximately six months previously. For this study, the participants were randomized to AED operation with or without dispatcher assistance during a simulated VF cardiac arrest. The proportions who successfully delivered a shock and the time intervals from collapse to shock were compared between the two groups., Results: The participants who received dispatcher assistance were more likely to correctly deliver a shock with the AED during the simulated VF cardiac arrest (91% vs 68%, p = 0.001). Among those who were able to deliver a shock, the participants who received dispatcher assistance required a longer time interval from collapse to shock [median (25th, 75th percentile) = 193 seconds (165, 225) for dispatcher assistance, and 148 seconds (138, 166) for no dispatcher assistance, p = 0.001]., Conclusions: Among older laypersons previously trained in AED operation, dispatcher assistance may increase the proportion who can successfully deliver a shock during a VF cardiac arrest.

Background: In the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial, patients with ventricular fibrillation or hemodynamically unstable ventricular tachycardia were randomly assigned to receive either an implantable cardioverter-defibrillator (ICD) or antiarrhythmic drug therapy. As part of the trial, patients were asked to participate in a prospective driving survey. The purpose of the survey was to determine what baseline factors and patient characteristics specifically predicted resumption of driving earlier than advised by current guidelines., Methods: Patients were surveyed anonymously as to their driving habits in the initial period after random assignment and every 6 months thereafter. AVID study coordinators were independently asked to assess their patients' driving status as well. The relation between baseline factors and time to resumption of driving was explored by means of Kaplan-Meier estimates for univariate analyses and the stepwise Cox proportional hazards regression model for multivariate analyses., Results: There were 802 patients who were eligible for assessment of driving status. The majority of patients (58%) resumed driving an automobile within 6 months of their index arrhythmia regardless of whether they received drug therapy or an ICD. By multivariate analysis, patients who were younger than 65 years of age, male, and college educated were more likely to drive early, as were patients whose index arrhythmia was ventricular tachycardia., Conclusions: Younger, college-educated men and those whose index arrhythmia is ventricular tachycardia are most likely to resume driving <6 months after the initiation of therapy for a potentially life-threatening ventricular arrhythmia. Patients with an ICD did not appear to resume driving later than those who were discharged on antiarrhythmic drugs alone.

The aim of this study was to describe changes in the life situation of patients with an implantable cardioverter defibrillator over a period of 1 year. A sample of 56 consecutive patients took part in the study. Life situation was measured through uncertainty in illness, satisfaction, and fear of the life situation. Descriptive statistics were used to present results, and analytical statistics were used to map out changes over time. Overall uncertainty showed a decrease over time. A statistically significant difference was found within the domain uncertainty related to information (P < 0.001). Satisfaction increased within the domains health-functioning, socio-economic, psychological-spiritual, and family. The ability to act within the domain health-functioning showed a statistical significance (P < 0.05). The domain life changes within fear in the life situation decreased and showed a statistical significance (P < 0.05). The overall life situation showed increased satisfaction as well as lower uncertainty and fear in the life situation. The research indicates that patients need more information about changes in the life situation after the implantable cardioverter defibrillator-implantation. The study encourages more humanistic, holistic research about patients' life situations as well as more education in teaching skills for health care personnel.

This study aimed at determining these factors--ventricular fibrillation (VF) in acute phase of myocardial infarction MI), thrombolytic therapy, beta-blockers after MI, cardiac rehabilitation--affect quality of life (QOL) during the follow-up. The study involved 100 patients (mean age 45.5 years), on the average 2 years after MI, MI has complicated VF in 50 patients. Questionnaire of QOL after MI developed internally, taking into account 26 features (clinical, emotional and social status), and estimating anxiety level (STAI) were used. Computer medical diagnostics "SyntMED" (Krefft's method) was used. In both groups after MI (complicated and not complicated VF) beneficial effect of: thrombolytic treatments in acute phase MI (0.65 vs conventional 0.45, p > 0.05), use of beta-blockers after MI (0.56 vs 0.41 p < 0.05), and cardiac rehabilitation (0.64 vs 0.44 p < 0.05) on value QOL were noted. Patients after MI complicated VF had higher level of anxiety. Patients who returned to work had higher index QOL (0.62 vs 0.39). Ventricular fibrillation complicated the acute phase of MI had no significant effect on follow-up QL.

The purpose of the present study was to assess the quality of life (QOL) and factors influencing QOL in patients 2 years after myocardial infarction (MI). The study was performed in 100 pts (mean age 45.5) mean 2 years after MI. 50 pts of studied group (mean age 42.5) were resuscitated from ventricular fibrillation (VF) complicating acute phase of MI. The control group consisted of 100 healthy subjects persons (mean age 53.5). The QOL index was assessed with the use of 2 types questionnaires: "Quality of Well-Being Scale" (QWB) and questionnaires of QOL including 26 factors in terms of: pain, dyspnoea, anxiety, depression, energy, sleep, emotions, mobility, social isolation, sexual activity, hobby, subjective emotional, distress, functional and social state and return to work. The QOL index was assessed using mathematical Krefft method. The average value of QOL index in patients 2 years following MI was significantly lower when compared with control group. The mathematical method of Krefft showed, that out of 26 features the most important diagnostic power factor for the QOL index were: self estimation of physical performance, return to work, the lifestyle and presence of stenocardial pain and dyspnoea. The pts resuscitated from VF revealed the higher level of anxiety.

Objective: To show cluster analysis as a potentially useful tool in defining common outcomes empirically and in facilitating the assessment of preferences for health states., Data Sources: A survey of 224 patients with ventricular arrhythmias treated at Kaiser Permanente of Northern California., Study Design/methods: Physical functioning was measured using the Duke Activity Status Index (DASI), and mental status and vitality using the Medical Outcomes Study Short Form-36 items (SF-36). A "k-means" clustering algorithm was used to identify prototypical health states, in which patients in the same cluster shared similar responses to items in the survey., Principal Findings: The clustering algorithm yielded four prototypical health states. Cluster 1 (21 percent of patients) was characterized by high scores on physical functioning, vitality, and mental health. Cluster 2 (33 percent of patients) had low physical function but high scores on vitality and mental health. Cluster 3 (29 percent of patients) had low physical function and low vitality but preserved mental health. Cluster 4 (17 percent of patients) had low scores on all scales. These clusters served as the basis of written descriptions of the health states., Conclusions: Employing a clustering algorithm to analyze health status survey data enables researchers to gain a data-driven, concise summary of the experiences of patients.

All 181 patients with malignant arrhythmias who have been provided with an implantable cardioverter-defibrillator (ICD) at the University Clinics of Muenster during the last 3 years, were investigated by a clinical questionnaire on quality of life (QOL). 132 patients answered and could be included in the study (response rate 73%). The mean age of the patients was 55 +/- 11.8 years, 73% males, 60% had already retired. In the general view 51% of the patients reported fair to excellent quality of life, while 24% gave a negative description of their QOL. 26% of the patients suffered from side-effects of the treatment, primarily from unspecific psychological complaints and ICD-related disturbances. "Unrest" was the predominant psychological complaint (64% of the patients), followed by rumification, shortness of breath, weakness and sleep disturbances. Somatic function and sex life were the functional areas primarily affected (more than half of the patients complaining about these). The "Psychological General Well-Being Index (PGWB)" showed reduced well-being in 61% of the patients. Comparing with the literature and regarding the PGWB-scales well-being, anxiety, and depression no significant differences could be found in comparison with other cardiologic samples after bypass-surgery or valve replacement. The results indicate the need of individual counseling and offers of psychosocial support for this highly strained group to reduce anxiety and to improve the quality of life in order to help the patient to gain greater overall benefit from the new ICD-therapy.

We examined Bortner scores for behavioral patterns and eight basic emotional dimensions named by Plutchik for patients with acute myocardial infarction who survived ventricular fibrillation and left ventricular failure. There were 70 patients, 48 men and 22 women ages 26 to 69 yr. (M = 54, SD = 8), admitted to the coronary care unit within 24 hours of the onset of a long-lasting chest pain. Six patients survived an episode of ventricular fibrillation that occurred within 24 to 48 hours after their admission. 15 patients developed left ventricular failure and were in Killip Classes II and III. Patients with acute myocardial infarction and left ventricular failure had mean Bortner scores significantly lower than others with acute myocardial infarction and were classed as Type B behavior. There was no difference in Bortner scores between patients with ventricular fibrillation and others with acute myocardial infarction. Patients with acute myocardial infarction and left ventricular failure scored significantly higher on Timid than others with acute myocardial infarction. Patients with acute myocardial infarction and ventricular fibrillation scored significantly lower on Depressed and higher on Distrust than other patients with acute myocardial infarction. Our findings suggest that patients with ventricular fibrillation and low scores on Depressed have good hospital prognosis. They are more critical and tend to reject people and ideas more than patients with acute myocardial infarction. This study suggests that the way in which patients with acute myocardial infarction react to their infarction, in terms of eight basic emotions and test patterns, is dependent on the complications of myocardial infarction.

Objective: Acute myocardial infarction is often accompanied by anxiety, but the effect of this emotion on recovery is unclear. The purpose of this study was to determine the association between patient anxiety early after acute myocardial infarction and the incidence of subsequent in-hospital complications., Methods: We assessed anxiety level within 48 hours of patient arrival at the hospital in 86 confirmed myocardial infarction patients. Anxiety was measured using the Brief Symptom Inventory. Myocardial infarction complications were defined as reinfarction, new onset ischemia, ventricular fibrillation, sustained ventricular tachycardia, or in-hospital death., Results: More complications were seen in patients with higher versus lower levels of anxiety (19.6% vs 6%; p = .001). Multiple logistic regression was used to control for those clinical and sociodemographic factors that can influence the incidence of complications and demonstrated that higher anxiety level was independently predictive of complications. Patients with higher anxiety levels were 4.9 times (p = .001) more likely to have subsequent complications., Conclusions: Anxiety early after myocardial infarction onset is associated with increased risk of ischemic and arrhythmic complications. This finding suggests that anxiety should be considered among the conventional risk factors for in-hospital acute myocardial infarction complications.

Purpose: The purpose of this study was to compare psychological reactions and family adjustment after sudden cardiac arrest (SCA) and internal cardioverter defibrillator (ICD) implantation in survivors who did and did not experience defibrillatory shocks the first year of recovery., Methods: Data were collected as part of a longitudinal prospective study that examined patient and family adjustment after SCA. SCA survivors and one family member per patient were interviewed and completed questionnaires three times within the first year (hospital discharge, 6 months, and 12 months) after SCA., Sample: Fifteen SCA survivors (13 men and 2 women) between the ages of 30 and 74 (mean 57 years) and one respective family member, usually the spouse, (mean age 53 years) participated. All SCA survivors had had primary ventricular fibrillation outside the hospital, had automatic defibrillators implanted while hospitalized, and were monitored for 1 year., Results: Participants were divided into shock and no shock groups based on activation of their ICD the first year. The mean number of shocks received in the shock group survivors was 26, with a range of 3 to 100. Anxiety, depression, anger, and stress levels were higher for both survivors and their family members in the group that received defibrillator shocks. Denial was high throughout the entire year in all survivors. Dyadic adjustment and family coping were not found to be significantly different between the no shock and shock groups. A trend toward reduction in family social support and dyadic satisfaction was noted in both groups with time., Conclusions: Both SCA survivors and their family members experience more psychological distress in the first year after ICD implantation if the defibrillator fires. Families in both shock and no shock groups report lower levels of family support and marital satisfaction the first year after SCA and ICD implantation.

The cardioverter defibrillator therapy has proven to be effective in preventing sudden cardiac death. However, there are only few reports that this kind of therapy will change the life of patients. Therefore, the purpose of the present study was to further evaluate this item. The quality of life of 195 patients with implanted cardioverter defibrillator (ICD) was investigated with the help of a questionnaire and a personal interview. An increased or unchanged quality of life was reported by 89% of patients. The acceptance of the therapy was high (92% of the patients). Anxiety was reported by 25% of patients, the estimation of the received shocks was depending on the amount of shocks. No influence was seen by the operative technique of implantation (epicardial versus transvenous lead system) with regard to the opinion of the patients toward the operation stress. The ICD gives a feeling of safety to 90% of the patients and this kind of therapy is marked by a high degree of acceptance.

Clinical experience suggests that the implantable cardioverter defibrillator (ICD) can reduce sudden cardiac death and total mortality in patients with malignant ventricular arrhythmia who meet the selection criteria for implantation. In addition to surgical problems, patients are faced with psychological and social adjustments. Patient acceptance for such therapy is marked by perceived concerns regarding device discharge, life-style alterations, and complications. We included 57 patients with ICDs in a study of their acceptance of the device. Results of a specially designed questionnaire (state-trait personality inventory) showed that 47 of 57 patients felt that their symptoms improved with the ICD system, 32 were constantly aware of the device, and 24 patients acclimated to the ICD system within less than 2 months. With respect to the need for battery replacement, only 27 patients requested a repeat electrophysiologic evaluation, 20 patients stated fear of ICD discharges, 12 patients revealed physical discomfort from the device, and limited quality of life occurred in eight patients. Fifty-five of 57 patients answered that it was worth having an ICD device implanted, 30 (53%) patients returned to active life, and 56 (98%) would advise another patient to have an ICD implantation if necessary. In conclusion, in general, the acceptance of the ICD as a tool for management of life-threatening ventricular tachyarrhythmias is very high. Quality of life and patient acceptance are important criteria for successful ICD therapy in addition to the improved survival rate.

Advances in the management of ventricular arrhythmias have improved patient survival, but not the uncertainty faced by those living with these arrhythmias. Managing the uncertainty in illness is considered essential to the maintenance of well-being and, therefore, quality of life. The purpose of this study was to determine the relationship between uncertainty and quality of life for adults with recurrent ventricular arrhythmias. Using a descriptive correlational design, 22 adults hospitalized with life-threatening ventricular arrhythmias completed questionnaires prior to discharge from the hospital. Data were collected using a demographic questionnaire, the Mishel Uncertainty in Illness Scale, the Quality of Life Index-Cardiac Version, and a single item self-rating scale for amount of worry. Results from the study indicated that greater quality of life for the health and functioning domain was significantly correlated with lower overall uncertainty and less ambiguity. Greater worry about the arrhythmia was associated with increased uncertainty and ambiguity, and poorer quality of life for the health and functioning domain. The results provide support for the aversive nature and negative impact of uncertainty on quality of life for patients with ventricular arrhythmias. Conclusions address clinical and research implications of these findings.

Neomammalian and paleomammalian (limbic) brain structures control different behaviors and the autonomic support specific to each. Both neural systems are involved in cardiovascular disorders. Our previous studies showed that bilateral cryoblockade of a neomammalian structure (the frontal lobes) reduces blood pressure elevations in experimental hypertension and prevents lethal arrhythmogenesis in experimental myocardial infarction. Other studies showed that bilateral lesions in a paleomammalian structure (amygdala) also reduce the blood pressure elevations. Thus, we hypothesized that cryoblockade of the amygdala would prevent lethal arrhythmogenesis. We found that cooling of cryoprobes implanted bilaterally in the amygdala prevented ventricular fibrillation in five of eight pigs during a 20-minute period of reversible myocardial ischemia, whereas cryoblockade in structures surrounding the amygdala (five pigs), unilateral cryoblockade in the amygdala (two pigs), or sham operations (three pigs) did not prevent ventricular fibrillation (p less than 0.003). In two of the five pigs with amygdaloid blockade, the cooling was reversed at 20 minutes while the coronary occlusion continued (24 hours), and still ventricular fibrillation did not occur. In all other cases, ischemia was reversed at 20 minutes so that the heart could recover; this enabled histochemical documentation that the heart was normal at the time(s) ischemia was induced, and it allowed within-subject control experiments. Amygdaloid cryoblockade produced a small but significant increase in heart rate (10 beats per minute) without a change in blood pressure. We conclude that the paleomammalian brain, like its neomammalian counterpart, mediates brain effects on fatal arrhythmogenesis.

The automatic implantable cardioverter defibrillator (AICD) has found a place in the treatment of sustained ventricular tachycardia and in survivors of sudden arrhythmic death. However, little is known about the psychological impact of this device on patients and their families. In a group of 20 AICD recipients, examined between 3 and 21 months post-implantation, the prevalence of psychiatric disorder was 50%. Following implantation, six patients suffered from adjustment disorder; three suffered from major depression; and one developed panic disorder. Psychiatric morbidity in patients was associated with psychopathology in family members, peri-operative AICD shocks, and social support that was perceived to be inadequate.

The hemodynamic, electrocardiographic, and coronary flow responses to a psychological test were studied in 13 pigs both in the absence (group 1, n = 8) and the presence (group 2, n = 5) of a transient occlusion of the left anterior descending coronary artery. The psychological test consisted of presenting food to a fasting but restrained animal for 3 minutes. In group 1, stress increased the heart rate from 128 +/- 5 to 176 +/- 8 beats/min (mean +/- SEM) and arterial pressure from 93 +/- 4 to 112 mm Hg. Comparing the individual increase in rate-pressure product with the increase in coronary conductance during the test, a parallel response was found in only two animals, whereas a relatively lower coronary conductance was observed in the remainder, suggesting vasoconstriction. Clinical signs of ischemia or life-threatening arrhythmias were never observed in this group of animals. Each group 2 animal underwent two occlusions of the left anterior descending coronary artery, randomly performed on separate days both in the presence and the absence of the food deprivation stress. When the latter was applied in the presence of occlusion, all animals developed ventricular fibrillation in less than 2 minutes (mean, 81.4 seconds). Conversely, only one animal had ventricular fibrillation when a 3-minute occlusion was performed without exposure to stress. This occurred despite the fact that more severe ischemia (as detected by an increase in left ventricular end-diastolic pressure and decreases in dP/dt and systolic pressure) was recorded at 3 minutes of occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)

In chronic experiments on rabbits, a delta-sleeping inducing peptide was tested for effects on the cardiac electric stability and onset of ventricular premature beats during experimental emotional stress. The peptide in a dose of 60 nm/kg was found to normalize the thresholds of ventricular fibrillation and its predictors and to decrease or abolish spontaneous ventricular premature beats occurring during the stress. This suggests that the delta-sleep-inducing peptide may be used to prevent cardiac arrhythmias during stresses.

Increasing evidence indicates that sudden death resulting from ventricular fibrillation may be triggered in some patients by behavioral and neural factors. In animal preparations, diverse psychologic stressors and augmented sympathetic neural traffic to the heart lower the vulnerable period threshold for ventricular fibrillation. Epidemiologic studies have demonstrated increased cardiac fatality after bereavement and unemployment, as it relates to social class and cultural dislocation, and as a function of level of education, psychologic stress, and social isolation. Ventricular premature beats (VPBs), which may be risk indicators of susceptibility to sudden death, are not affected by perturbations of the peripheral autonomic nervous system. However, differing psychologic stressors increase, whereas their abatement diminishes, VPB frequency and grade. The most potent stressors relate to the recall of emotionally charged experiences. Such stressors are uniquely individual and cannot be readily replicated. Among the most significant factors to reduce VPBs are non-rapid eye movement sleep and increases in vagal neural activity. Psychological precipitants are demonstrable in about 20% of patients experiencing malignant ventricular arrhythmias. A promising new avenue for investigation relates to the role of various central neurotransmitters and their dietary precursors in cardiac neural traffic. Augmenting central serotonin by administering its tryptophan precursor reduces sympathetic neural activity and protects the heart against ventricular fibrillation.