Transcript Chronic anxiety in ICD patients: A multi

Depression and anxiety in atrial fibrillation patients CoRPS is this undertreated?
Susanne S. Pedersen, Professor of Cardiac Psychology
Center of Research
on Psychology
in Somatic diseases
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Disclosures
Moderate speaker or consultancy fee from:
• Medtronic
• St. Jude Medical
• Cameron Health
• Sanofi Aventis
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Affiliations
Prof.dr. Susanne S. Pedersen
• CoRPS - Center of Research on
Psychology in Somatic diseases, Tilburg
University, The Netherlands
• Thoraxcenter, Erasmus Medical Center,
Rotterdam, The Netherlands
• Department of Cardiology, Odense
University Hospital, Denmark
Phone: + 31 (0) 13 466 2503
E-mail: [email protected]
www.tilburguniversity.nl/corps
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Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
CoRPS
Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
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What is atrial fibrillation
• Most common type of sustained
cardiac arrhythmia, affecting
over 2 million patients in the
United States
• Not directly life-threatening, but
associated with poor quality of
life and increased risk of stroke,
heart failure and mortality
• Pathophysiology: Disorganized
electrical activity of the atria
• AF treatment
– rate control
– rhythm control
e.g. electrical cardioversion, radiofrequency
ablation
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Types of atrial fibrillation
Severity
(i) First detected episode of AF
(ii) Paroxysmal AF - self-terminating episodes lasting no
longer than seven days, commonly less than 24 hours
(iii) Persistent AF - non-self-terminating episodes lasting
more than 7 days, requiring electrical or pharmacological
cardioversion to terminate
(iv) Permanent AF - fails to terminate after cardioversion,
or is accepted by the patient and the physician
Fuster et al. ACC/AHA/ESC 2006 Guidelines for the management
of patients with atrial fibrillation. Circulation, 2006;114:700–52
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Risk factors for incident AF
Bajpai et al. US Cardiovascular Disease 2007
What
about
distress
as
a
risk
factor
for
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incident AF?
Framingham offspring study (N = 3682 )
Eaker et al. Psychsom Med 2005;67:692-6
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Lone AF - definition
• AF in the absence of the above risk factors or underlying
heart disease
• Accounts for 12-30% of all AF
• Accounts for 20-45% of AF in younger patients
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AF prevalence rates
Prevalence based on large population-based cohorts:
• 0.9%
• 3-5% in people older than 65 years
• 10% or higher in people >80 years
Life-time risk of AF:
• From age 40 years onwards - one in four for both
men and women
• In the absence of congestive heart failure or
myocardial infarction - one in six
Feinberg et al. Arch Intern Med 1995;155:469–73
Stewart et al. Heart, 2001;86:516–21
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Projected prevalence of AF in 2050
Miyasaki et al. Circulation 2006;114:119-25
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Economic burden of AF
Principal driver of cost difference
Kim et al. Circulation Cardiovasc Qual Outcomes online 3 May 2011
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Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
Distress
in
AF
patients
compared
to
other
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cardiac populations
Redhead et al. J Psychosom Res 2010;69:555-63
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Distress at baseline and at 6 months
AF: N = 101
Hypertensive: N = 97
Mean anxiety scores
remain stable over
a 6-month period
Thrall et al. Chest 2007;132:1259-64
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Stability of distress over time – what about
HRQoL scores...
Lone AF: N = 70
NS
Prevalence of distress in AF
patients is equivalent to that
↓
seen in other cardiac populations
and persists once manifest
Lane et al. J Psychosom Res 2009;203-10
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Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
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Treatment of anxiety and depression in AF
7/17 studies focusing on anxiety/depression and reporting %
Author (year)
N (patients)
Study
design
(mths)
Ariansen (2011)
27 (AF)
C
HADS
13% depression
17% anxiety
11%
974 (AF-CHF)
P (24-74)
BDI-II
32% depression
?
Lange (2007)
54 (AF)
P (2)
HADS
24% depression
32% anxiety
0%
Lane (2009)
70 (lone AF)
P (B, 6, 12)
STAI-S
STAI-T
39%, 31%, 36%
41%, 27%, 21%
?
Ong (2006)
93 (AF)
C
HADS
11% depression
8%
Redhead (2010)
50 (AF)
C
HADS
16% depression
26% anxiety
7%
13%
Thrall (2007)
101 (AF)
P (6)
BDI
STAI-S
38% depression
28% anxiety
?
Frasure-Smith (2009)
Measure
% distress
% psychotropics
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Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
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Depression and AF recurrence
Lange et al. J Psychosom Res 2007;63:509-13
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Depression and AF recurrence
Multivariate analysis of the risk of
AF recurrence including variables
found to be predictive in univariate
analysis
Lange et al. J Psychosom Res 2007;63:509-13
Cardiovascular death-free survival stratified by
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depression symptoms and rhythm- versus rate-control
N=947 comorbid AF-CHF
Atrial Fibrillation and Congestive
Heart Failure trial
• Rate-control (i.e., betablockers and digoxin) versus
rhythm-control (i.e.,
antiarrhythmic medications
and electrical cardioversion)
• 32% had BDI-II scores 14 (mild
to moderate symptoms of
depression)
Frasure-Smith et al. Circulation 2009;120:134-40
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ICD patients - posttraumatic stress
symptoms and mortality
N = 147
Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30
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Type D personality - burden of increased
negative emotions and inhibition
No!!
I do not want to
share my emotions
with others…
Type D ?
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ICD patients - anxious Type D patients and
ventricular arrhythmias
N = 391
van den Broek, Denollet et al. J Am Coll Cardiol 2009;54:531-7
N = 371
HR: 3.65; 95%CI: 1.57-8.45; p = .003
2-year mortality (%)
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ICD patients - Type D personality and preimplantation ICD concerns and mortality
20
18
16
14
12
10
8
6
18.2%
5.2%
4
2
0
Type D and concerns
Pedersen, Theuns, Jordaens et al. Europace 2010;12:1446-52
None or one risk marker
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Why would depression be bad for AF patients?
CAD
Healthrelated
behaviours
Elevated
blood
pressure
Hemostatic
changes
Endothelial
damage
Depression
Activation
of the
HPA-axis
 HRV
Noncompliance
Risk factor
clustering
Release
of stress
hormones
Inflammation
Poor
prognosis
Also effects on QoL, adherance, and compliance !!!
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Overview
• Epidemiology of atrial fibrillation (AF)
• Prevalence of distress in AF
• Is distress treated in AF patients?
• Consequences of distress in AF patients
• Research and clinical implications
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Emotional distress in AF
2/3 of patients experience
significant symptoms:
Tachycardia-related
(sympathetic):
Reporting of symptoms often not in
palpitations, exercise intolerance
Suggests that thiswith
is not objective
only an electrophysiological
concordance
presence of
Congestion-related:
shortness
of breath,
disorder,
but that other factors,
like emotional
distress,
AF
rhythm
of energy
might affectfatigue/lack
symptom perception,
and maybe also
recurrence of AF episodes
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Disease-specific patient-rated measures:
Quality of life
Measure
Acronym
Origin
Items Domains
Atrial Fibrillation Effect on QualiTy-of-Life
AFEQT
USA
20
(i) Symptoms
(ii) Daily Activities
(iii) Treatment Concern
(iv) Treatment Satisfaction
Atrial Fibrillation Quality of Life
questionnaire
AF-QoL
Spain
18
(i) Psychological activity
(ii) Physical activity
(iii) Sexual activity
AFSS
Canada
14
Subjective and objective
ratings of AF disease
burden:
(i) Frequency
(ii) Duration
(iii) Severity of episodes
Toronto AF Severity Scale
There are many more...
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Disease-specific patient-rated measures:
Anxiety and depression
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Conclusions
• Prevalence of depression and anxiety in AF equivalent to
other cardiac populations ≈ 1 in 4 patients
• Symptoms of depression and anxiety seem to be
undertreated – underdetected???
• Few large-scale prospective studies available
• Distress in AF patients likely has consequences for
recurrence and mortality
• Need for developing disease-specific distress measures
• Need to identify these patients in clinical practice
Can
a
nurse
and
a
computer
manage
AF
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better than a heart doctor?
• 712 AF patients followed for 22 months
• Randomized to care in an AF-clinic model
or to usual care (UC; cardiologist)
• Fewer patients in the AF-clinic group
reached the primary endpoint: 51 (14.3%)
versus 74 (20.8%) in the UC group
o
o
Patient deaths:
distress
levels
???
Heart-related
AF-clinic
= 1.1%
versus UC = 3.9%
No behavioral/psychological
Heart
related hospitalizations: AF-clinic =
13.5%
versus UC = 19.1%
intervention
trials in AF
patients targeting distress...
Hendriks et al. ACC 2011; Abstract 3016-12
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Device Conference, 3-4 November 2011,
Tilburg, the Netherlands
Living in a Device World: Focus on Recent Challenges and Tools to Improve
Clinical Care for Patients with an Implantable Cardioverter Defibrillator
Themes
Selection of invited faculty
• OVERCOMING THE SHOCK OF THE ICD
• Nico Blom (MD, PhD), Leiden University Medical Center, NL
• Matthew Burg (PhD), Yale School of Medicine, USA
More information available
on:
• Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE
• www.tilburguniversity.edu/device2011
DEACTIVATION OF THE ICD AND END OF LIFE
• Dorothy Frizelle (PhD), University of Hull, UK
ISSUES
• ICD REGISTRIES AND THE INCLUSION OF THE
PATIENT PERSPECTIVE
• NEGLECTED SUBGROUPS
• CRT SELECTION AND RESPONSE
• THE DO’S AND DON’TS OF PATIENT
COMMUNICATION
• Jens Brock Johansen, (MD, PhD), Odense University Hospital, DK
• Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE
• Mathias Meine (MD, PhD), University Medical Center Utrecht, NL
• Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL
• SEXUALITY IN ICD PATIENTS
• Samuel Sears (PhD), East Carolina University, USA
• BEHAVIORAL INTERVENTIONS
• Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK
• LOOKING INTO THE FUTURE
• Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL