INTRODUCTION:

Sudden cardiac death (SCD) due to arrhythmias is a crucial cause of mortality globally, claiming more than 350,000 lives per year in United States alone.⁽¹⁾In India, there is paucity of databut in rural South India about 17% of deaths other than accidental deaths are due to SCD.⁽²⁾ The incidence of SCD is roughly 0.1% this suggests that one million Indians are at risk of SCD annually. Coronary Artery Disease (CAD) is a major risk factor among the vast majority of these individuals, and involves a much younger population.⁽³⁾

For the primary prevention of SCD, American College of Cardiology, American Heart Association, North American Society for Pacing and Electrophysiology recommends implantation of cardioverter defibrillator particularly in CAD with old myocardial infarction (MI) and left ventricular ejection fraction (LVEF) ≤ 30%. Various cardiac conditions as valvular heart diseases, congenital heart diseases, cardiomyopathies and channelopathies leads to ventricular dysfunction that further places these patients at long term risk of life threatening ventricular arrhythmia. Patient with these conditions benefit from an Implantable Cardioverter Defibrillator (ICD) for sudden death prevention^(4,5,6,7). ICD isan effective and life saving biomedical deviceimplanted over the pectoralis major muscle in a subcutaneous pocket recommended for termination of potentially lethal ventricular arrhythmias as ventricular tachycardia (VT), ventricular fibrillation (VF). These devices are programmed to deliver low energy cardioversion and antitachycardiac pacing (ATP) as a therapy for slower hemodynamically stable VT and immediate high-energy shock known as therapy shocks or defibrillatory shocks for termination of VT, VF.⁽⁸⁾

There is a substantial growth in patients living with ICD. Problems related to ICD implantationare as common adverse events related to the procedure, lead and generatorbut mostly because of the experience of repeated shock and may be associated with significant psychological and physical distress^(9,10). The unforeseen outcomes of living with ICD are reported as anxiety disorders, attentional biases,alteration in daily functions, avoidance behaviour, panic symptoms as well as difficulty in retaining information provided by nurses and physicians.^{(11,12,13,14)} Various clinical and contextual factors adds to their misery like pre-procedural mood destabilizing experiences, surviving cardiac arrest, prolonged hospitalisation, constant fear of recurrence of arrhythmias as these are unpredictable. Technology is sure to have some negativeconsequences, which might limit the capabilities and choices in daily life of the recipients. A technology is accepted only when its users signify that the benefits overweigh the negatives^(15,16,17). Patients with one or multiple shocks are frequently seen at emergency departments, hospital wards, or ICD clinics but physicians and nurses feel less comfortable in managing their unique concern related to therapeutic shock. Therefore, it is imperative that personnel working in these environments should have speciﬁc knowledge concerning the management of ICD-related problems.⁽¹¹⁾Also adaptation to home environment is impaired when the expectations from the procedure is unlike actual experience.^(18,19,20)

In patients with chronic illness, it is necessary to provide concrete information that is in line with the patient’s illness experience.⁽²¹⁾ For this, one has to understand their experiences comprehensively. Hence, it is necessary to identify patient’s health needs and updatemanagement strategies. Explaining and exploring these areas can facilitatein the provision of detailed instructions early after device implantation, preferably prior to hospital discharge.

The current study aims to examine specific implanted device related physical and psychosocial concerns in patients living with ICD.

MATERIALS AND METHODS:

Cross-sectional approach was used. Consecutively, 62patients who were attending their routine follow-up care after ICD implantation on an outpatient basis from a arrhythmia clinic of a tertiary care hospital were approached. Out of 62, 60 patients were willing to participate in study and hence were enrolled. Inclusion criteria included English/Hindi-speaking, ICD recipientsadults older than 18 years who were able to communicate responses to complete the questionnaires. Exclusion criteria included persons with confusion, dementia, or unstable patients who were unable to complete the questionnaires were excluded from the study. Determination of mental status was based on the opinion of the consultants at the clinical or hospital.

Physical concerns questionnaire (PCQ) was used to measure their knowledge and physical symptoms. Physical symptoms were also further explored using quantitative methods, to assess the therapy shock related experiences. Psychosocial concerns were assessed using Florida patients acceptance survey (FPAS) and Florida shock anxiety scale (FSAS).

PCQ is a self- administered questionnaire that was prepared by researcher in English/Hindi. To increase the data quality, most of the questions were adapted from previously conducted qualitative studies along with expert opinions with some changes based on the local context. This structured questionnaire has two parts: Part 1 (subjective concerns questionnaire)–To assess physical concerns in terms of presence or absence of physical symptoms. Part 2 (ICD related knowledge questionnaire) – To assess physical concerns in terms of general facts related to ICD. Internal consistency of part 1 is 0.78 and of part 2 is 0.77. Symptom burden scores were calculated from overall scores of question in part 1. The minimum-maximum possible score ranges between 0–11. Knowledge score were calculated from knowledge questionnaire (part 2). The minimum-maximum possible score ranges between 0 – 19. The total knowledge score was then classified into two categories: Adequate:10-19 and Less than adequate: 0 – 9.

Florida patients acceptance survey^(22,23) (FPAS), is a standardized tool which consists of 18 items related to four domains including return to function, device-related distress, positive appraisal, and body image concerns. It’s Cronbach’s α is 0.83, internal consistency of each of the subscale ranges from 0.74 -0.89. The total score of FPAS ranged from 18-90. Sample with a total mean score greater than 76.01 was considered to have greater device acceptance. Mean scores were used for comparison in return to life domain (54.799), positive appraisal domain (80.9), device related distress domain (10.088) and body image concerns domain (20.526).

Florida shock anxiety scale(FSAS)^(24,25)is a standardized tool which consisted of two subscales with ten items rated on a 5- point Likert scale from 1 (not at all) to 5 (all of the time). The Florida Shock Anxiety Scale indicates clinically significant therapy shock related anxiety. The greater shock anxiety values reported on the FSAS(total score), the greater the rated disruptiveness of shocks to everyday life. Cronbach’s α : 0.89

Statistical analysis:

SPSS IBMVersion 20 was used. Appropriate descriptive and inferential statisticswas used for data analysis. Association of two group means were done using independent t test or Wilcoxon rank-sum test. Association of more than two group means were done using one way ANOVA or Kruskal–Wallis test. Post hoc analysis was used for finding relationship between subgroups. Correlation between continuous variables were measured through pearson correlation. For statistical significance a p value of<0.05 was considered.

RESULTS:

Demographic and clinical profile of the sample are tabulated in table 1 and table 2 respectively.

Table 1. Demographic characteristics of the sample (N=60)

Variable	Category	n	%
Gender	Female	9	15.0
Gender	Male	51	85.0
Educational qualification	Primary	6	5.0
	Secondary	12	58.3
	Graduation and above	42	36.7
Marital status	Unmarried	4	6.7
	Married	53	88.3
	Widow	1	1.7
	Divorced	2	3.3
Monthly income	<15000	21	35.0
Monthly income	>15000	39	65.0
Area of residence	Rural	24	40.0
Area of residence	Urban	36	60.0
religion	Hindu	53	88.3
	Muslim	4	6.7
	Christian	1	1.7
	Sikh	2	3.3
Types of family	Nuclear	47	78.3
Types of family	Joint	13	21.7
Occupation	Student	1	1.7
	Employed	33	55.0
	Unemployed	26	43.3

Table 2. Clinical profile of the sample (N=60)

Clinical profile		Frequency	%
Duration after implantation	3 months to 6 months	15	25.0
	6 months to 12 months	7	11.7
	12 months to 24 months	4	6.7
	>24 months	34	56.7
NYHA class	Class I	25	41.7
	Class II	22	36.7
	Class III	13	21.7
Ejection fraction	<35	39	65.0
Ejection fraction	>35	21	35.0
Other illness	Overall	26	43.3
	Neurology	1	1.7
	Urology	4	6.7
	Orthopaedics	4	6.7
	Endocrinology	16	26.7
	Skin related	1	1.7
	Pulmonary	1	1.7
	Sarcoidosis	1	1.7
Drugs	Beta blocker	47	78.3
	Calcium channel blocker	4	6.7
	Anti-arrhythmic	33	55.0
	ACE inhibitors	28	46.7
	Statin	24	40.0
	Cardiac glycoside	8	13.3
	Newer anti-anginal	4	6.7
	ARB	10	16.7
	Anti-platelet	26	43.3
	Anticoagulant	6	10.0
	Nitrate	11	18.3
	Diuretic	34	56.7

Table 3. Description of therapy shock related chest pain in 14 ICD recipients, recovery experience from therapy shockandKnowledge scores among subjects

Pain characteristics		Mean+/-SD	Minimum- Maximum
Pain severity		5.50+/-2,21	1-9
		Frequency (Percentage)
Pain location	Chest	12 (80.0%)
	Abdomen	2(13%)
	Whole body	1(7%)
Pain duration	Less than 5 minutes	11(79%)
	<5 minutes but less than 15 minutes	1(7%)
	Upto 1 day	2(14%)
Recovery experience	Frequency (%), N=30
Therapy shock related response	Description	Frequency (%)
	Relaxation	13(43.3%)
	Confusion	4(13.3%)
	Anxiety/ irritability	13(43.3%)
Time required to resume normal daily routine	Description	Frequency (%)
	Less than 1 hour	20 (66.7%)
	>1-3 hour	7 (23.3%)
	Upto 12 hours	3(10.0%)
Knowledge class	Knowledge score, frequency (%), N=60
Adequate	41(68.3%)
Inadequate	19(31.7%)

Table 4. Domains of psychosocial concerns among the subjects in the study.

Domains assessed		Scale scores	Total (N=60) Mean+/- SD
Florida patient acceptance scale	Return to life	54.799	65.52 +/- 20.37
	Positive appraisal	80.9	82.81+/-20.41
	Device related distress	10.088	34.25+/-23.35
	Body image concerns	20.526	25.00+/-31.04
	Total score	76.01	71.22+/-17.06
Florida shock anxiety scale (total score)		15.44	17.12+/-7.40

Factors associated with symptom burden, anxiety and device acceptance in ICD recipients

Table 05 correlation of physical and psychosocial concerns with selected clinical and demographic variables.

Variables		Symptom burden score		FPAS Score		FSAS score
		Median (min- max)	P value	Mean+/-SD	P value	Mean+/-SD		P value
Education	Primary (6)	2(2-6)^£	0.96	64.16±30.90 ^€	0.41	18.50±11.4 ^€		0.03* #0.031^a*
	Higher secondary (12)	2(0-8)		68.47±17.23		21.75±7.62
	Graduation and above (42)	2.50(0-11)		73.01±14.48		15.60±6.19
Residence	Urban (36)	2(0-11)^∞	0.001*	74.21±15.37^¥	0.09	16.00±5.67^¥		0.15
	Rural (24)	4(0-8)		66.73±18.76		18.79±9.30
NYHA class	I (25)	1(0-4)^£	0.001* #0.001^b* #0.007^c*	77.33±16.20 ^€	0.04* #0.083^b #0.124^c #1.00^d	16.60±6.29 ^€		0.74
	II (22)	3(1-11)		66.89±16.67		18.09±9.14
	III (13)	3(1-6)		66.02±16.35		16.46±6.41
Variables		Symptom burden scores		FPAS scores		FSAS Scores
		Pearson r	p value	Pearson r	p value	Pearson r	p value
Age		-0.110	0.40	0.333	0.009**	-0.173		0.186
Ejection fraction		-0.170	0.195	-0.038	0.77	-0.021		0.875
Duration of implantation		0.287	0.02*	-0.131	0.319	0.222		0.088
Number of therapy shock		0.550	0.000**	-0.358	0.005**	0.476		0.000**
Body Mass Index(BMI)		-0.270	0.037*	0.250	0.05	-0.272		0.03*

^{Note--
1 £-}Wilcoxon rank sum test, ^{€- One
way ANOVA , a- Higher secondary vs graduate and above, b- NYHA class I and NYHA
class II,c-}NYHA class I and NYHA Class III, ^d- NYHA Class II and NYHA class III , ^{∞- Kruskal Wallis test, ¥- Independent sample t test,
* significant at p<0.05, ** Correlation is significant at the 0.01 level.}

DISCUSSION:

In the present study, majority of them were male, this is in agreement with other studies⁽²⁶⁾ and the reason for this dominancy is attributable to difference in autonomic changes because of hormonal differences between male and female. Mean age of participants is 50.57+/- 11.46 which is in agreement with previous studies^(6,22) and is in contraindication with Celikyurt U et al (2013)⁽²⁷⁾, Mirjam H et al (2011)⁽²⁸⁾, Burns J.M. et al (2004)⁽²⁹⁾ as these studies have subjects with mean age of greater than 60 years. Regarding comorbidities, endocrinological disorders (26.7%) namely diabetes and thyroid disorders were prevalent in this study. Similar findings have been reported byIngvlid M etal (2010)⁽³⁰⁾ where only 16% were diabetic. In the present study, majority (53.3%) of the participants had shortness of breath, (35%) had palpitations, 5% had fainting spells, similar findings were reported as pre-procedural symptoms in a study by Marcel J. Met al (2003)⁽⁶⁾ except that 19% had fainting or syncope pre-proceduarly. In the present study, 30% participants reported to have shoulder pain, this finding is in line with Celikyurt U et al (2013)⁽²⁷⁾ where 52% reported shoulder pain. The knowledge scores regarding ICD related factors in thepresent study is inadequate in 31.7% of the population, this finding is in line with Stromberg A et al (2012)⁽³¹⁾ as this study has reported, 29% had insufficient knowledge in relation to ICD. Present study reported low mean scores for patient acceptance (71.22+/-17.06) as well as higher levels of clinically significant anxiety (17.12+/-7.40) which is in line with findings of Vazquace L.D et al 2010⁽³²⁾, CinazFl et al 2010⁽²¹⁾ but contradictory to Burns J.L. (2004)⁽²⁹⁾.Greater number of therapy shocks were associated with greater anxiety and lower device acceptance, this finding is in congruence with Passman R et al (2007)⁽³³⁾, Schron E Bet al (2002)⁽³⁴⁾but contradictory to Piotrowicaz K. et al (2007)⁽⁵⁾, Udis et al (2013)⁽¹⁶⁾. Study conducted by Lang S. et al (2007)⁽³⁵⁾and Piotrowicz K et al (2007)⁽⁵⁾have found that NYHA class, EF, limited access to health carefacilities, presence of palpitations, fainting spells factors as independent determinants of poor mental and physical health. In the present study, there was a significant association between symptom burden and place of residence but no association between NYHA class and EF with mental health of the subjects, which in in line with the findings of Jacq F et al (2009)⁽³⁶⁾. Greater burden scores among rural population indicates greater number of rural subjects had to live with physical discomfort that are not intervened or treated. This depicts, the inadequacy of present health care infrastructure. Higher BMI was associated with lesser symptom burden and lesser anxiety. This finding is in agreement with Piotrowicz K et al (2007)⁽⁵⁾, and Mehmet K Aktas et al (2013)⁽³⁷⁾. Strengths of this study lies in use of standardized questionnaires. This study has several limitations as lack of device interrogation data, conducted in a single centre, convenience sampling, and lack of data regarding the pre-implant symptoms and critical factors were not assessed. More studies with larger sample size framed in longitudinal design, assessing effectiveness of psychosocial interventions among ICD recipients, comparison of ICD patients who had and who hadn’t experienced shock therapy are further recommended.

CONCLUSION:

Physical concerns in terms of symptom burden among ICD recipients are varied and require evaluation from health care professional. The concerns among ICD recipients in itself is a complex field of study that can be affected by several factors other than symptom burden, pre-shock anxiety and device acceptance. This study uncovers that the patients are living with various physical and psychosocial problems and insufficient knowledge regarding the implantable cardioverter defibrillator.

REFERENCES:

1. About Sudden Cardiac Arrest | Sudden Cardiac Arrest Foundation [Internet]. [cited 2014 Dec 31]. Available from: http://www.sca-aware.org/about-sca

2. Rao BH, Sastry BKS, Chugh SS, Kalavakolanu S, Christopher J, Shangula D, et al. Contribution of sudden cardiac death to total mortality in India-A population based study. Int J Cardiol. 2012 Jan 26;154(2):163–7.

3. Madhavan SR, Reddy S, Panuganti PK, Joshi R, Mallidi J, Raju K, et al. Epidemiology of sudden cardiac death in rural South India - insights from the andhrapradesh rural health initiative. Indian Pacing Electrophysiol J. 2011 Jul;11(4): 93–102.

4. Naik N, Juneja R. ICD for primary prophylaxis of sudden cardiac death: an Indian perspective. J Assoc Physicians India. 2007 Apr; 55 Suppl: 47–53.

5. Piotrowicz K, Noyes K, Lyness JM, McNitt S, Andrews ML, Dick A, et al. Physical functioning and mental well-being in association with health outcome in patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial II. Eur Heart J [Internet]. 2007 Feb 12 [cited 2015 Jan 2]; Available from: http://eurheartj.oxfordjournals.org/content/early/2007/02/12/eurheartj.ehl485

6. Kofflard MJ., Ten Cate FJ, van der Lee C, van Domburg RT. Hypertrophic cardiomyopathy in a large community-based population: clinical outcome and identification of risk factors for sudden cardiac death and clinical deterioration. J Am CollCardiol. 2003 Mar 19;41(6):987–93.

7. Olshansky B, Sullivan RM. Sudden Death Risk in Syncope: The Role of The Implantable Cardioverter Defibrillator. Prog Cardiovasc Dis. 2013 Jan; 55(4):443–53.

8. Wathen MS, Sweeney MO, De Groot PJ, Stark AJ, Koehler JL, Chisner MB, et al. Shock Reduction Using Antitachycardia Pacing for Spontaneous Rapid Ventricular Tachycardia in Patients with Coronary Artery Disease. Circulation. 2001 Aug 14;104(7):796–801.

9. Freeman JV, Wang Y, Curtis JP, Heidenreich PA, Hlatky MA. Physician Procedure Volume and Complications of Cardioverter-Defibrillator Implantation.Circulation. 2012 Jan 3;125(1):57–64.

10. Van den Broek KC, Tekle FB, Habibović M, Alings M, van der Voort PH, Denollet J. Emotional distress, positive affect, and mortality in patients with an implantable cardioverter defibrillator. Int J Cardiol. 2013 May 10;165(2):327–32.

11. Braunschweig F, Boriani G, Bauer A, Hatala R, Herrmann-Lingen C, Kautzner J, et al. Management of patients receiving implantable cardiac defibrillator shocks. EP Eur. 2010 Dec 1;12(12):1673–90.

12. Moss AJ, Zareba W, Hall WJ, Klein H, Wilber DJ, Cannom DS, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002 Mar 21;346(12):877–83.

13. Dixit NK. Attentional bias in patients with implantable cardioverter defibrillators: Examining mechanisms of hypervigilence and anxiety [Internet]. University of Florida; 2008 [cited 2015 Jan 2]. Available from: http://gradworks.umi.com/33/67/3367020.html

14. Sethares KA, Sosa M-E, Fisher P, Riegel B. Factors associated with delay in seeking care for acute decompensated heart failure. J CardiovascNurs. 2014 Oct;29(5):429–38.

15. Saito N, Taru C, Miyawaki I. Illness experience: living with arrhythmia and implantable cardioverter defibrillator. Kobe J Med Sci. 2011 Dec; 58(3): E72–81.

16. Udlis KA. The impact of technology dependency on device acceptance and quality of life in persons with implantable cardioverter defibrillators. J CardiovascNurs. 2013 Dec; 28(6): E65–73.

17. Jurgens CY, Hoke L, Byrnes J, Riegel B. Why do elders delay responding to heart failure symptoms? Nurs Res. 2009 Aug; 58(4): 274–82.

18. Lam C, Smeltzer SC. Patterns of Symptom Recognition, Interpretation, and Response in Heart Failure Patients: An Integrative Review. J CardiovascNurs. 2013; 28(4): 348–59.

19. Lemon J, Edelman S, Kirkness A. Avoidance behaviors in patients with implantable cardioverter defibrillators. Heart Lung J Crit Care. 2004 Jun; 33(3): 176–82.

20. Strachan PH, de Laat S, Carroll SL, Schwartz L, Vaandering K, Toor GK, et al. Readability and Content of Patient Education Material Related to Implantable Cardioverter Defibrillators. J CardiovascNurs. 2012 Nov; 27(6): 495–504.

21. Cinar FI, Tosun N, Kose S. Evaluation of an education and follow-up programme for implantable cardioverter defibrillator-implanted patients. J ClinNurs. 2013; 22(17-18): 2474–86.

22. Burns JL, Serber ER, Keim S, Sears SF. Measuring patient acceptance of implantable cardiac device therapy: initial psychometric investigation of the Florida Patient Acceptance Survey.J CardiovascElectrophysiol. 2005 Apr; 16(4): 384-90.

23. Keren A, Sears SF, Nervy P, Shaw J, Green MS, Lemery R, et al. Psychological adjustment in ICD paients living with advisory fidelis leads. J. CardiovascElectrophysiol. 2011; 22(1): 57-63

24. Kuhl EA, Dixit NK, Walker RL, Conti JB, Sears SF. Measurement of patient fears about implantable cardioverter defibrillator shock: an initial evaluation of the Florida Shock Anxiety Scale. Pacing Clin Electrophysiol PACE. 2006 Jun; 29(6): 614-8.

25. Ford J, Finch JF, Woodrow LK, Cutitta KE, Shea J, Fischer A, et al.The Florida Shock Anxiety Scale (FSAS) for Patients With Implantable Cardioverter Defibrillators: Testing Factor Structure, Reliability, and Validity of a Previously Established Measure. Pacing ClinElectrophysiol. 2012 Sep; 35(9): 1146-53.

26. Bhavnani SP, Pavuluri V, Coleman CI, Guertin D, Yarlagadda RK, Clyne CA, et al. The Gender-Paradox among Patients with Implantable Cardioverter-Defibrillators: A Propensity-Matched Study. Pacing ClinElectrophysiol. 2013; 36(7): 878–84.

27. Celikyurt U, Agacdiken A, Bozyel S, Argan O, Sade I, Vural A, et al. Assessment of Shoulder Pain and Shoulder Disability in Patients With Implantable Cardioverter-Defibrillator. J Interv Card ElectrophysiolInt J Arrhythm Pacing. 2013 Jan; 36(1): 91-4.

28. Mastenbroek MH, Denollet J, Versteeg H, et al. Trajectories of patient-reported health status in patients with an implantable cardioverter defibrillator. Am J Cardiol. 2015; 115(6): 771‐777. doi: 10.1016/j.amjcard.2014.12.035

29. Burns JL, Sears SF, Sotile R, et al. Do patients accept implantable atrial defibrillation therapy? Results from the Patient Atrial Shock Survey of Acceptance and Tolerance (PASSAT) Study. J CardiovascElectrophysiol. 2004; 15(3): 286‐291. doi:10.1111/j.1540-8167.2004. 03406.x

30. Ingvild M Morken TMN. Perceptions of healthcare professionals' support, shock anxiety and device acceptance among implantable cardioverter defibrillator recipients. J Adv Nurs. 2014;

31. Strömberg A, Fluur C, Miller J, Chung ML, Moser DK, Thylén I. ICD recipients’ understanding of ethical issues, ICD function, and practical consequences of withdrawing the ICD in the end-of-life. Pacing ClinElectrophysiol PACE. 2014 Jul; 37(7): 834–42.

32. Vazquez LD, Conti JB, Sears SF. Female-specific education, management, and lifestyle enhancement for implantable cardioverter defibrillator patients: the FEMALE-ICD study. Pacing ClinElectrophysiol PACE. 2010 Sep; 33(9): 1131–40.

33. Passman R, Subacius H, Ruo B, Schaechter A, Howard A, Sears SF, et al. Implantable cardioverter defibrillators and quality of life: results from the defibrillators in nonischemic cardiomyopathy treatment evaluation study. Arch Intern Med. 2007 Nov 12; 167(20): 2226–32.

34. Schron EB, Exner DV, Yao Q, Jenkins LS, Steinberg JS, Cook JR, et al. Quality of Life in the Antiarrhythmics Versus Implantable Defibrillators Trial Impact of Therapy and Influence of Adverse Symptoms and Defibrillator Shocks. Circulation. 2002 Feb 5; 105(5): 589–94

35. Lang S, Becker R, Wilke S, Hartmann M, Herzog W, Löwe B. Anxiety Disorders in Patients with Implantable Cardioverter Defibrillators: Frequency, Course, Predictors, and Patients’ Requests for Treatment. Pacing ClinElectrophysiol. 2014; 37(1): 35–47.

36. Jacq F, Foulldrin G, Savouré A, Anselme F, Baguelin-Pinaud A, Cribier A, et al. A comparison of anxiety, depression and quality of life between device shock and nonshock groups in implantable cardioverter defibrillator recipients. Gen Hosp Psychiatry. 2009 May; 31(3): 266–73.

37. Aktas MK, Zareba W, Huang DT, McNitt S, Polonsky S, Chen L, et al. The Effect of Weight Loss on Clinical Outcomes in Patients Implanted With a Cardiac Resynchronization Therapy Device-A MADIT-CRT Substudy. J Card Fail. 2014 Mar; 20(3): 183–9

Received on 10.06.2020 Modified on 09.07.2020

Asian J. Nursing Education and Research. 2020; 10(4):463-470.

DOI: 10.5958/2349-2996.2020.00099.3