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Psychophysiologic and Affective Parameters Associated With Pain Intensity of Cardiac Cardioverter Defibrillator Shock Discharges

From the Klinik und Poliklinik für Psychosomatische Medizin, Psychotherapie und Medizinische Psychologie, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany (J.B., K.-H.L.); German Heart Center Munich, Munich, Germany (C.S.); GSF-National Research Center for Environment and Health, Institute of Epidemiology, Neuherberg, Germany (J.B., K.-H.L.).

Address correspondence and reprint requests to K.-H. Ladwig, PhD, MD habil, Prof., Klinik und Poliklinik für Psychosomatische Medizin, Psychotherapie und Medizinische Psychologie, Klinikum rechts der Isar der TUM, Langerstraße 3, 81675 München, Germany. E-mail ladwig{at}gsf.de

Objective: Pain caused by intracardiac shock discharge of an implanted cardioverter defibrillator (ICD) is an important clinical issue in the treatment of ICD patients. The present study aimed to examine whether the strength of perceived shock pain is influenced by affective and psychophysiologic parameters.

Methods: Among 204 ICD patients drawn from the German Heart Center Munich, 95 patients (46.6%) experienced 1 shock discharge. Pain perception (PPC) was measured by a visual analog scale ranged from 0 to 100 points. Standard instruments were administered to measure psychological distress. A startle paradigm was assessed to measure psychophysiologic arousal with skin conductance responses (SCR) and electromyogram responses (EMG) as dependant variables. Classification and regression tree (CART) analysis was applied to assess the effects of psychodiagnostic and psychophysiologic parameters on pain perception.

Results: Mean ICD shock PPC was 53.7 points (SD 31.6), with a median of 59.0 points (interquartile range 30–80). Pain intensity was highly associated with shock discomfort (p < .001) but was largely uninfluenced by clinical and sociodemographic factors. CART analysis revealed patients with one shock and low EMG magnitude (4.15 µV) as subclass with the lowest mean PPC (21.9 points; 95% confidence interval [CI], 4.6–39.1), whereas patients with >one shock experience and an anxiety score >7 (Symptom Checklist-90) expressed the highest mean PPC (74.8 points; 95% CI, 60.5–89.2). Without heightened anxiety, an increased EMG amplitude and impaired EMG habituation yielded a mean PPC of 71.2 (95% CI, 61.6–80.9).

Conclusions: Augmented PPC of ICD shocks is predominantly associated with the number of perceived shocks, postshock anxiety, and accompanied by heightened levels of EMG magnitude and impaired EMG habituation, which points to sensitization of central neural structures.

Key Words: implanted cardioverter defibrillator • shock discharge • pain perception • psychophysiology • anxiety

Abbreviations: CART = classification and regression tree; CI = confidence interval; EMG = electromyogram; HAD-S = Hospital Anxiety and Depression Scale; ICD = implanted cardioverter defibrillator; SCL-90 = Symptom Checklist-90; SCR = skin conductance responses; SC = skin conductance; VAS = visual analog scale.

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