New-Onset Anxiety, Depression an Ongoing Risk for ICD Patients

April 30, 2021

Testing for anxiety or depression should be offered periodically — perhaps for months to years — to patients with implantable cardioverter defibrillators (ICD), not just in the early period after implantation, suggests a prospective cohort study.

Results showed a 2% to 4% rate of new-onset anxiety and depression at each of four scheduled follow-up assessments over 2 years in a cohort of more than 1000 ICD recipients, compared with how they reportedly felt at the time they received their device. Cumulatively, 11.3% of the cohort eventually tested positive for new depression, and 14.5% for new anxiety.

The findings suggest that a one-time screening for anxiety and depression when patients receive their ICDs "is not sufficient," said Susanne S. Pedersen, PhD, University of Southern Denmark and Odense University Hospital.

"We know from the literature that if you as an ICD patient suffer from either anxiety or depression, you have an increased risk of worse health outcomes," she observed.

The current results suggest that "we are missing quite a few" such patients, which has potential consequences not only for their quality of life, but also their risk for ventricular tachyarrhythmias and mortality, said Petersen when reporting the study April 24 at the virtual European Heart Rhythm Association 2021 congress.

Also in the analysis of men and women receiving a first ICD for either primary or secondary prevention, older age seemed protective against both new-onset anxiety and depression, as did a self-perception of being physically able.

Neither anxiety nor depression was predicted by educational level, employment status, or being in NYHA heart failure class 3 or 4.

However, the analysis of ICD-recipient responses suggested, "for some reason, if you're married, then you are at greater risk of new-onset and anxiety, which is a bit difficult to explain," Pedersen said.

Of note, the experience of receiving an ICD shock during follow-up was not associated with new-onset anxiety.

But the strongest observed predictor of either new-onset anxiety or depression turned out to be an ICD recipient's testing responses that pointed to a "type D" personality. That more than doubled the risk for both conditions.

In the literature, type D is a label for a chronically "distressed" personality type characterized by pessimism and anxiety, along with social inhibition, that has been associated with poor outcomes in a range of studies, but the reliability of which as a cardiovascular prognosticator has also been challenged.

"It's those individuals who experience a lot of negative emotions while not wanting to share these emotions with others," Pedersen explained. "And in some studies, type D has been associated with mortality in patients with heart disease."

The study's 1040 patients receiving an ICD for the first time at five centers across Denmark completed validated questionnaires on their levels of anxiety, depression, and quality of life and were prospectively followed. They repeated the self-assessment tests at 3, 6, 12, and 24 months.

New cases of anxiety and depression were identified by positive scores on the Hospital Anxiety and Depression Scale (HADS), not formal clinical criteria; subclinical anxiety and depression also affect risk, Pedersen explained.

In adjusted analyses, being married or with a partner elevated the risk for new-onset anxiety by 66% (P = .044), a secondary prevention indication raised it 43% (P = .048), self-reported physical functioning in the lowest tertile increased the risk 48% (P = .047). But it jumped 150% for patients identified with a type D personality (P < .001).

For new-onset depression, smoking was associated with risk elevated by 113% (P = .001), self-reported physical functioning in the lowest tertile by 64% (P = .02), and a type D personality by 153% (P < .001).

Older age cut the risk for new-onset anxiety 46% (= .002) and new-onset depression by 43% (P = .013).

The corresponding 2-year rates overall in Denmark "range from around 1% to 2%," Pedersen observed. "That's just to say that it's not really normal that you would see this accumulated incidence over 24 months, at least in a Danish population," she said, referring to the study's patients with first ICDs.

Pedersen had no disclosures.

European Heart Rhythm Association (EHRA) 2021. News from ICD therapy. New onset depression and anxiety in patients with an implantable cardioverter defibrillator during 24 months of follow-up. Presented April 24, 2021.

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