International Journal of Cardiology 220 (2016) 360364

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International Journal of Cardiology

journal homepage: www.elsevier.com/locate/ijcard

Psychological correlates, allostatic overload and clinical course in

patients with implantable cardioverter debrillator (ICD)
Sara Gostoli a,,1,2, Matteo Bonomo a,1,2, Renzo Roncuzzi b,1,2, Mauro Bif c,1,2,
Giuseppe Boriani c,1,2, Chiara Rafanelli a,1,2
a
Department of Psychology, University of Bologna, Bologna, Italy
b
Division of Cardiology, Bellaria Hospital, Bologna, Italy
c
Division of Cardiology, Sant'Orsola-Malpighi Hospital, Bologna, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Background: Implantable cardioverter debrillator (ICD) is a key treatment option for both primary and second-
Received 11 May 2016 ary prevention of sudden cardiac death. Despite this, there is a growing number of studies showing that ICD is
Accepted 26 June 2016 often associated with post-implantation deleterious psychosocial effects, even in the absence of medical
Available online 27 June 2016 complications. Knowledge about the predictive role of pre-ICD psychological prole is scant. The present research
aims to describe patients' pre-ICD psychological prole, focusing on acute and chronic distress, such as anxiety,
Keywords:
depression, type D personality, psychosomatic syndromes and allostatic overload (AO), and to evaluate if these
Allostatic overload
Anxiety
psychological variables could affect ICD outcomes and survival.
Diagnostic Criteria for Psychosomatic Research Methods: 117 consecutive patients (74.4% males; mean age = 63.1 13.7 years) underwent psychological
(DCPR) assessment prior to ICD implantation. Data on ICD-related complications and death were collected up to
Depression 26 months after the intervention.
Implantable cardioverter debrillator Results: At baseline, 36.8% of the sample had anxiety and 17.9% depression. Among psychosomatic syndromes,
Type D personality psychological factors affecting medical conditions were the most frequent (37.6%). 12.8% presented with type
D personality, whereas 16.2% showed moderate AO and 4.3% severe AO. 25.6% of the patients had post-ICD com-
plications and 6% died. Severe AO was the only predictor of survival.
Conclusion: Our ndings show that a reliable evaluation of stress and the inability to cope with it (allostatic over-
load) may help to identify patients at higher risk of post-ICD complications and death. Such sensitive index, more
than traditional psychiatric diagnostic criteria, may help the physician to identify easily manifestations of distress
and clinically relevant information, which could affect medical illness outcomes.
2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Implantable cardioverter debrillator (ICD) has emerged as an im-
portant treatment option for patients who are at risk of sudden cardiac
death (SCD) [1]. Randomized trials have consistently shown that ICD
implantation decreases mortality in patients with heart failure and re-
duced left ventricular function, as well as patients who have suffered a
cardiac arrest [2,3]. Recent guidelines recommend ICD for both primary
and secondary prevention of SCD [4,5]. Primary prevention consists in
reducing total mortality of patients with non-ischemic dilated cardio-
myopathy or ischemic heart disease at least 40 days post-myocardial
Corresponding author at: Department of Psychology, University of Bologna, Viale Berti
Pichat 5, 40127 Bologna, Italy.
E-mail address: sara.gostoli2@unibo.it (S. Gostoli).
1
These authors contributed equally to this manuscript.
2
This author takes responsibility for all aspects of the reliability and freedom from bias
of the data presented and their discussed interpretation.
infarction, with left ventricular ejection fraction (LVEF) of 35% or less,
NYHA Class II or III symptoms, on chronic guideline-directed medical
therapy, who have reasonable expectation of meaningful survival for
more than 1 year [5]. Secondary prevention by means of ICD is indicated
before discharge of patients who survive sustained ventricular tachycar-
dia or brillation, provided that arrhythmia is not due to transient or
reversible ischemia, re-infarction, or metabolic abnormalities [4].
Although the implantation is quite simple, medical complications
such as bleeding, infection, pneumothorax, cardiac perforation, lead
dislodgement, and death, have to be taken into account [6]. Among
long term unwanted events, inappropriate shocks occur nowadays in
2 up to 6% ICD patients [7,8]. ICD implantation is often associated with
deleterious psychosocial effects, with about 50% of recipients reporting
elevated levels of anxiety and depression resulting from the fear of ICD
discharge and device failure, decrease in physical activity, and negative
lifestyle changes (such as the inability to drive or return to work) [9]. In
addition, some patients develop severe psychiatric problems, such as
post-traumatic stress disorder (PTSD), after receiving inappropriate

http://dx.doi.org/10.1016/j.ijcard.2016.06.246
0167-5273/ 2016 Elsevier Ireland Ltd. All rights reserved.
 S. Gostoli et al. / International Journal of Cardiology 220 (2016) 360364
shocks [10]. However, even in absence of medical complications and
inappropriate shocks experience, 2533% of ICD patients report psycho-
logical problems following ICD implantation [11]. For these reasons,
most of research have focused on psychological problems risen after
ICD implantation. The difculties in adaptation for both these patients
and their families [12] resulted in an increasing need to address psycho-
logical distress [13,14].
Studies on the role of a previous history of psychiatric disorders are
rare. Pedersen et al. [11] found that pre-ICD psychological impairments,
such as specic personality traits, rather than ICD-related complications,
could be strongly associated with post-ICD emotional distress, such as
anxiety. It has been found that a positive history of depression predicts
poor health status, such as impaired health-related quality of life [15,
16]. The manifestation of psychological distress such as anxiety and de-
pression prior to ICD implantation may be independent or attributed to
a combination of factors, including fear for ICD implantation or the un-
derlying heart disease [1719]. Several studies also found high rates of
type D personality in pre-ICD patients [20,21] associated with the risk
for developing adverse health outcomes [22,23]. Thus, as highlighted
by Pedersen and colleagues [24], the identication and treatment of
subgroups of patients with stable high emotional distress levels is nec-
essary, since chronic emotional distress and impaired health status
may precipitate ventricular arrhythmias and mortality in patients with
ICD. Recent studies performed in medical settings have focused on the
importance to detect allostatic overload (AO), which occurs when
cumulative interactions of life events and chronic stressors exceed
individual resources [25,26]. In cardiology, it discriminated patients at
high risk for psychological distress [27,28]. No studies, however, have
been conducted among ICD patients.
Other research revealed that psychosomatic syndromes, evaluated
by Diagnostic Criteria for Psychosomatic Research-DCPR [29,30], are
strictly associated to cardiac diseases [27,30]. To our knowledge, only
a small study [31] assessed DCPR syndromes among patients with ICD.
Only few studies have examined the role of baseline psychological
characteristics such as anxiety [31], type D personality and self-
reported health-related quality of life [10,24,32,33] as risk factors for
ventricular arrhythmias and death in ICD patients.
The present study aims to describe the baseline psychological and
psychosomatic prole of patients undergoing the implantation of ICD,
focusing on acute and chronic distress, and evaluate if these psycholog-
ical variables could affect the clinical course of ICD patients. Specically,
the goal and novelty of this study is to verify if pre-existing psycholog-
ical correlates could predict ICD outcomes and survival.
2. Methods
2.1. Sample
The study includes a sample of 117 consecutive patients (74.4% males; mean age =
63.1 13.7 years, range from 26 to 86 years) undergoing ICD implantation from July
2012 to November 2015 at the Department of Cardiology of the Policlinico S. Orsola-
Malpighi, Bologna. Patients underwent the psychological assessment before the interven-
tion and at multiple follow-up, up to 24 months after the implantation. Written informed
consent was obtained from all the participants. The study protocol conforms to the ethical
guidelines of the 1975 Declaration of Helsinki as reected in a priori approval by the Local
Ethic Committee.
2.2. Assessment
2.2.1. Anxiety and depression
Structured Clinical Interview for DSM-IV-TR Disorders (SCID) [34,35], Axis I, was ad-
ministered in order to identify anxiety and depressive diagnoses. SCID is an excellent
tool that meets the needs of both clinician and investigator. The SCID can be applied to
any person thanks to his easy understanding, except to people with severe cognitive im-
pairment. Time of administration varies from 45 to 90 min, depending on the complexity
of patient medical history and psychological status.
2.2.2. Psychosomatic syndromes
The Diagnostic Criteria for Psychosomatic Research (DCPR) [29,30] integrate somatic
disorders with the DSM-IV and International Classication of Disease (ICD-10) in a multi-
axial approach. The basic idea of this new classication system is to think in terms of
361
psychosomatic syndromes, highlighting the variety of somatic and mental responses
that individuals may have produced in various circumstances during life [36]. The DCPR
allows translating into operational tools psychosocial variables resulting from psychoso-
matic research. According to the psychosomatic approach, patient condition must be con-
sidered holistically, as the psychological factors and the biological components interact
during an organic disorder, affecting its course and the psychological response of the sub-
ject [37]. Twelve psychosomatic syndromes were operationalized with a specic diagnos-
tic criterion, and divided into three clusters: abnormal illness behavior (nosophobia,
thanatophobia, health anxiety, illness denial), psychological factors affecting medical
conditions (alexithymia, type A behavior, irritable mood, demoralization), and somati-
zation (functional somatic symptoms secondary to a psychiatric disorder, persistent so-
matization, conversion, reaction to anniversaries). The DCPR is an observer rated, semi-
structured interview with closed questions, and dichotomous yes or no answers, referring
to the last twelve months. The instrument showed good psychometric properties [38].
2.2.3. Type D personality
Type D personality is measured by 14-item Type D Scale (DS-14) [39]. The scale con-
sists in 14 items, divided into two scales (7 items each): negative affectivity and social in-
hibition. The answers are on a 5-point Likert scale, ranging from 0 (false) to 4 (true). Both
scales have a cut-off value 10, beyond which the presence of type D personality can be
assumed.
2.2.4. Sub-clinical symptoms of psychological distress
Symptom Questionnaire (SQ) [40] is a self-report measure, based on the Symptom
Rating Test by Kellner and Shefeld [41]. It consists of 92 dichotomous (yes/no, true/
false) items that make the instrument easy to understand and fulll (those are important
features when the questionnaire is administered to people with poor verbal skills). The
questionnaire consists in four scales (depression, anxiety, anger-hostility and somatic
symptom) and the scoring is calculated by assigning one point for each positive response.
The maximum score is 23 and higher scores indicate higher psychological distress; if the
score exceeds one or two standard deviations (SD) from the average of general population,
the distress is being considered as moderate, but if it exceeds two SD the presence of
severe psychological distress can be assumed [40]. Due to its sensitivity, SQ proved to be
a highly effective instrument in predicting the change in psychological and psychosomatic
issues.
2.2.5. Psychological well-being
The Psychological Well-Being scale (PWB), short version (42 items), measures the
presence of psychological well-being [42]. PWB is a self-rating and multidimensional
questionnaire, which includes the six domains of Ryff's psychological well-being model:
autonomy, environmental mastery, personal growth, positive relations with others, pur-
pose in life and self-acceptance [43]. The higher the score, the higher psychological well-
being is. Patients must indicate their level of agreement or disagreement with the items
using a 7-point Likert scale, ranging from 0 (not my case) to 6 (that is exactly my case).
2.2.6. Health-related quality of life
The 36-item Short Form Health Survey (SF-36) [44] is a self-rated test, accurate and
fast to be administered. Usually, it is used for medical population and it is very sensible
in valuating health status changes [45]. The 36 questions refer to eight subscales: physical
activity (10 items), role limitations due to physical health (4 items), role limitations due to
emotional problems (3 items), physical pain (2 items), perception of general health status
(5 items), vitality (4 items), social activities (2 items), mental health (5 items), and a single
question about the change in health status. The different dimensions are included in three
main domains: physical quality of life, mental quality of life, overall quality of life. All SF-36
questions are referred to the four weeks prior the assessment, except for the question
about the change of the health status, which considers the last year. The test includes
both dichotomous (yes/no) and on a Likert scale answers.
2.2.7. Allostatic overload
The operationalization of the concept of allostatic overload is based on specic
clinimetric criteria developed by Fava and colleagues [26]. Since the assessment of life
events by a detailed interview method, such as the Interview for Recent Life Events [46]
is unlikely to be endorsed in practice, even if certainly the gold standard, the Psychosocial
Index (PSI) [47] has been chosen as a reliable compromise. PSI is a short clinimetric index,
tailored to a busy clinical setting, for the assessment of stress and related psychological
distress (allostatic load). It offers a synthesis of previously validated instruments: the
Screening List for Psychosocial Problems [48], the Stress Prole [49], the Psychological
Well-Being scales [50,51] and the Illness Attitude Scales [52]. All this information may
help formulate a global clinical judgment of an individual's assets and coping skills in deal-
ing with his/her current life situation. AO Criterion A requires the presence and identiable
stressor, either as a recent life event or as prolonged exposure; the stressor must be judged
as exceeding or taxing the individual's coping skills when evaluated. The presence of an
acute or chronic stressor was established on patient's reporting of at least one chronic
stressor or life event comprised in the Psychosocial Index [47] stress subscale, as assessed
by items 3240 and 4754. The perceived feeling of inability to cope prociently with the
situation was identied through at least one positive answer to items 43 and/or 44. Both
conditions were deemed necessary to satisfy criterion A requirements. Criterion B requires
the stressor to be associated with at least 1 manifestation among psychiatric symptoms
(B1), psychosomatic symptoms (B2), impaired functioning (B3) or compromised well-
being (B4). Furthermore, the manifestations must occur within 6 months after the onset
362 S. Gostoli et al. / International Journal of Cardiology 220 (2016) 360364

of the stressor. Based on the available information from the PSI, the degree of psycholog- Table 1
ical distress was determined by reaching a score above 11.5 (75th percentile) on the PSI Relationship among baseline variables and survival in ICD patients.
psychological distress subscale (items 13 to 27). Similarly, the presence of impaired psy-
chological well-being was determined by reporting a cumulative score equal or lower Socio-demographic and N (%) Mean SD Hazard ratio (95% p
than 7 (25th percentile) on items 41, 42, 45, 46, 55. The presence of AO was thus deter- clinical variables CI)
mined by satisfying both criteria A and B. Age 63.1 13.7 1 (0.981.03) NS
Gender
2.3. Statistical analysis Male 87 (74.4)
Female 30 (25.6) 1.52 (0.773.01) NS
The SPSS software, version 20.0, was used in order to run the statistical analyses. Sta- Psychiatric and psychosomatic
tistical signicance was set to p = 0.05, two tailed. Descriptive analyses were run in order diagnoses
to describe the study population at baseline in terms of socio-demographic variables, psy- DSM depression 21 (17.9) 2.83 (0.879.2) NS
chological questionnaires (SQ, PWB, DS-14 and SF-36) mean scores, type D personality, DSM anxiety 43 (36.8) 1.39 (0.692.8) NS
DSM and DCPR clusters frequencies. DCPR abnormal illness 34 (29.1) 1.45 (0.693.08) NS
AO has been calculated on the basis of the clinimetric criteria mentioned above. Two behavior
categories have been identied: moderate AO (criterion A + criterion B, dened as high DCPR somatization 7 (6.0) 2.99 (0.4121.82) NS
psychological distress OR low psychological well-being) and severe AO (criterion DCPR psychological factors 44 (37.6) 1.39 (0.72.75) NS
A + criterion B, dened as high psychological distress AND low psychological well-being). affecting medical conditions
Cox model hazard-ratio was derived. To select appropriate covariates for statistical Type D personality 15 (12.8) 1.14 (0.43.21) NS
control, baseline psychological mean scores (SQ, PWB, DS-14 and SF-36) and diagnoses Allostatic overload
(DSM depression/anxiety, DCPR, type D personality and moderate/severe AO) were tested Moderate AO 19 (16.2) 0.65 (0.291.49) NS
in univariate Cox regression analysis. Those variables signicantly related to post-ICD Severe AO 5 (4.3) 0.18 (0.060.51) 0.001
complications in univariate analysis were also entered into the multivariate Cox regres- Psychological questionnaires
sion analysis, adjusted for sex and age. We used the KaplanMeier method and Logarith- Symptom Questionnaire
mic Rang (Log Rank) to estimate survival curves. Anxiety 6.5 4.9 1.06 (11.13) 0.049
Among post-ICD complications, heart failure, hospitalizations due to cardiac prob- Depression 5.9 4.1 1.03 (0.951.11) NS
lems, supraventricular tachycardia, ICD extraction due to an infection, coronary arteries Somatization 7.7 5.2 1 (0.941.07) NS
surgery, ICD re-evaluation, deep vein thrombosis, atrial tachycardia, dyspnea and all- Hostility 3.6 3.6 1.04 (0.951.13) NS
cause mortality were included. The mean period of survival was 14.8 11.2 months. Psychological Well-Being scales
Autonomy 35.1 5.1 1.05 (0.981.13) NS
Environmental mastery 33.5 5.7 1.03 (0.971.09) NS
3. Results
Personal growth 31.3 5.9 1 (0.951.06) NS
Positive relations 36.2 5.6 0.99 (0.941.05) NS
63.2% of patients were married, whereas 17.1% were single, 6% Purpose in life 29.2 6.5 1.01 (0.961.06) NS
common-law wife/husband, 6% widow/widower, 4.3% divorced, and Self-acceptance 32.8 6.2 0.99 (0.941.04) NS
3.4% separated. 32.5% had a junior high school degree, 29.1% a high 14-item Type D scale
Negative affectivity 8 6.7 0.99 (0.91.09) NS
school degree, 22.2% primary school certicate, and 16.2% master de-
Social inhibition 7.3 6.5 0.95 (0.851.07) NS
gree or higher level of education. One third had retired from employ- Psychosocial Index
ment (53%). Psychological distress 7.9 6.0 1 (0.951.06) NS
With regard to the medical prole, 66.7% of patients had congestive Psychological well-being 8.6 1.5 1.01 (0.811.26) NS
Stress 2.3 1.9 0.99 (0.841.17) NS
heart failure: 5.1% NYHA class I, 28.2% NYHA class II, 19.7% NYHA class
Abnormal illness behavior 0.7 1.1 1.04 (0.781.4) NS
III, and 1.7% NYHA class IV. 50.4% of the patients had a history of coro- 36-item Short Form Health Survey
nary artery disease; 19.7% atrial brillation and 20.5% a family history Physical health-related quality of life 54.2 21.0 1 (0.981.01) NS
of heart diseases. Among medical comorbidities, 48.7% of the patients Mental health-related quality of life 58.4 18.9 1 (0.981.01) NS
had hypertension, 25.6% diabetes, 17.9% chronic kidney failure, 15.4% Total health-related quality of life 58.1 19.4 0.99 (0.981.01) NS

peripheral vascular diseases, and 8.5% hyperthyroidism or hypothyroid-

ism. All patients regularly received multiple drug therapy: 89.7% -
blockers, 80.3% ACE inhibitors, 79.5% diuretics, 40.2% anticoagulants,
30.8% antithrombotic agents and 2.6% antiarrhythmics. At baseline,
DSM anxiety disorders were more frequent than depressive disorders
(36.8% versus 17.9%) (Table 1). Concerning DCPR syndromes, the most
represented cluster including psychological factors affecting medical
conditions (37.6%), followed by abnormal illness behavior (29.1%) and
somatization (6%) clusters (Table 1). 12.8% of the total sample showed
type D personality (Table 1). 16.2% of the sample (N = 19) presented
with AO of middle entity (high psychological distress OR well-being im-
pairment), while 4.3% (N = 5) showed a severe AO (high psychological
distress AND well-being impairment) (Table 1).
Of the total sample, 37 (31.6%) showed negative outcomes after ICD
implantation. 7 (6%) patients died (most of them for cardiac causes) and
30 (25.6%) had at least one post-ICD complication. Among post-ICD
complications, 20% were related to ICD implantation (3.4% hospitaliza-
tion for ICD re-evaluation, 0.9% pending skin erosion of the ICD pocket,
and 0.9% inappropriate shock) and 80% to cardiac illness (6.8% atrial -
brillation, 4.3% ventricular tachycardia, 3.4% hospitalizations for cardiac
disease such as heart failure, cardiac shock, coronaropathy and venous
thrombosis, 2.6% supraventricular tachycardia, 1.7% cardiac surgery,
and 1.7% paroxysmal ventricular tachycardia). Among the variables ex-
amined as potential risk factors for post-ICD complications, only base-
line score of anxiety (SQ) and severe, but not moderate, AO attained
statistical signicance (p b 0.05) in univariate analysis (Table 1). In par-
ticular, 80% of the patients with severe AO experienced ICD-related
complications or death. No one of the remaining psychological variables
resulted to be predictive of survival. In multivariate analysis (controlled
for age and sex), however, anxiety (SQ) lost its signicance, whereas se-
vere AO did not (HR: 4.57 [95% condence interval {CI}: 1.5713.29];
p = 0.005). KaplanMeier survival curves for post-ICD complications
by severe AO are presented in Fig. 1 (Log Rank(1) = 13.27; p b 0.001).
4. Discussion
In this study, the psychological prole of patients undergoing ICD
implantation is quite in line with literature. Indeed, a systematic review
[18] conducted on 45 studies from 1996 to 2009, showed that the prev-
alence of anxiety ranged from 27% to 63%, whereas the prevalence of de-
pression from 10% to 36%. Our results conrm the high prevalence of
these psychiatric disorders among ICD patients. Concerning DCPR syn-
dromes, as easily conceivable, the most represented cluster was that
of psychological factors affecting medical conditions, due to its strong
association with cardiac illness [27,30,53,54]. On the same line,
Banihashemian and colleagues [31] found greater percentages of such
DCPR diagnoses (27.3% type A behavior, 22.7% irritable mood and
18.2% demoralization) than those of DSM diagnoses in 36 ICD patients.
The higher rates of DCPR syndromes, rather than DSM psychiatric
 S. Gostoli et al. / International Journal of Cardiology 220 (2016) 360364
Fig. 1. Survival curves of patients with and without severe allostatic overload (AO).
diagnoses, sustain once more the importance of introducing the DCPR
evaluation in a multidimensional assessment, since it offers the possibil-
ity to obtain a wider characterization of these patients in comparison
with traditional nosography [29,55]. In the present study, the frequency
of type D personality (12.8%) is lower than that found in Starrenburg
et al. [20] and Mastenbroek et al. [21] research, where it ranged from
21% to 23%. This may be due to the smaller size of our sample than
those of the mentioned studies.
Concerning self-rated questionnaires, patients of the present study
reported mean scores of health-related quality of life similar to those
of the same kind of patients found in literature [20]. Regarding subclin-
ical psychological symptoms (SQ) and psychological well-being (PWB),
there are no studies in literature using the same measures to assess ICD
patients. However, if compared with similar population with chronic
cardiac conditions, such as atrial brillation, ICD patients reported sim-
ilar mean scores on both SQ and PWB [56]. Moderate AO has been diag-
nosed in 16.2% of the total sample, severe AO in 4.3%. The frequency of
moderate AO is quite in line with that found by Porcelli and colleagues
[27] in patients with chronic cardiovascular diseases (essential hyper-
tension and coronary heart disease). However, Ofdani and Ruini [57]
found a much higher prevalence of AOS (41%) compared with our re-
sults. This marked difference might be likely due to a number of reasons
including sampling (they recruited blood donors on a voluntary basis
versus consecutive patients receiving ICD), procedure (they recruited
healthy volunteers who might be more interested in participating in a
psychological evaluation because of experienced distress), and age
(they recruited younger subjects aged an average of 37 years while
our patients had a mean age of 63).
Concerning the clinical course of patients with ICD, we found com-
plications related to the cardiac illness course (20.5%), ICD implantation
(5.1%) and all-cause mortality (6%). To the best of our knowledge, there
are no studies on cardiac illness-related outcomes, whereas most of the
research on post-ICD course focuses on ICD-related complications, inap-
propriate/appropriate shocks and mortality. All-cause mortality in these
patients occurs in up to 15.2% [58,59], a slightly higher rate than that
found in the present research, probably due to the longer follow-ups
of previous studies. Inappropriate shocks range from 1.5% to 8.3% of
the patients [7,8]. A recent review by Ezzat et al. [60] found a 9.1% rate
of ICD-related complications, excluding inappropriate shocks. Our re-
sults show a lower rate of the latter complications (4.2%). This could
be explained by the fact that in the literature there is a great heteroge-
neity of data on ICD-related complications, which highlights the need
to standardize classications of post-ICD complications, as pointed out
by the authors [60].
363
In contrast with previous research, we did not nd any of the tradi-
tional psychological risk factors, such as anxiety, depression and type D
personality [6166] to predict survival. We found that the only predic-
tive factor was severe allostatic overload (AO). Findings from previous
studies suggest that AO is associated with worse health conditions and
plays a signicant role in the susceptibility (exacerbating disease pro-
cesses depending on the type of stressor involved and/or the duration
of its inuence on an organism), course, and outcome of cardiovascular
diseases, such as hypertension, atherosclerosis, coronary artery disease
and myocardial infarction [67]. Mental and psychosocial stressors
through the sympathetic nervous system have been found to have del-
eterious inuences on the cardiovascular system [67].
Our study includes obvious limitations due to its preliminary nature
such as limited sample size and lack of assessment of stress biomarkers
(e.g. erythrocytes, leukocytes, triglycerides, cholesterol, cortisol, C-
reactive protein, glucose, and insulin) relevant for both ICD clinical
course and AO. Nonetheless, our ndings show that a reliable evaluation
of AO, merging different clinical information otherwise assessed by sev-
eral instruments, may help to identify those patients at higher risk of
post-ICD complications and death. AO criteria may thus be considered
a global clinimetric index for detecting conditions that might adversely
inuence course and progression of the medical illness [57]. Hence, such
clinimetric index regarding stress and the ability to cope with it, more
than the traditional psychiatric diagnostic criteria, may help the physi-
cian to identify distress manifestations and clinically relevant informa-
tion easily. Indeed, the ultimate goal in treating patients with long-
course illnesses should be to prevent or decrease the negative impact
of excessive distress on individuals' health and quality of life.
Conicts of interest
The authors report no relationships that could be construed as a con-
ict of interest.
Funding source
None.
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