Impact of psychosocial risk factors on outcomes of patients undergoing catheter ablation for ventricular tachycardia

Studies have demonstrated that psychological stressors can facilitate the induction of ventricular tachyarrhythmias (VT), however, there is a lack of evidence on the impact of psychosocial risk factors (PSRFs) on the outcomes of patients undergoing VT ablation (1Lampert R. Joska T. Burg M.M. et al.Emotional and physical precipitants of ventricular arrhythmia.Circulation. 2002 Oct 1; 106: 1800-1805Crossref PubMed Scopus (273) Google Scholar). Therefore, we sought to analyze the association of PSRFs with outcomes in patients undergoing VT ablation from a large, nationally representative, and contemporary sample of the United States population. The National Readmissions Database (NRD) was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing VT ablation as described previously (2Sharma P. Tripathi B. Naraparaju V. et al.Short-term outcomes associated with inpatient ventricular tachycardia catheter ablation.Pacing Clin Electrophysiol. 2020 May; 43: 444-455Crossref PubMed Scopus (4) Google Scholar). Due to the de-identified nature of the NRD dataset, the need for informed consent and Institutional Review Board approval was waived (3Healthcare Cost and Utilization Project. Overview of the Nationwide Readmissions Database (NRD)". https://www.hcup-us.ahrq.gov/nrdoverview.jsp.Google Scholar). Patients were then categorized by the exposure of interest, which was defined as the presence of ≥1 psychosocial risk factor (PSRF). PSRFs were divided into 5 domains including limited cognitive understanding, substance abuse, psychiatric disease, low socioeconomic status, and uninsured status, as validated previously (4Agarwal S. Munir M.B. Khan M.Z. et al.Impact of Psychosocial Risk Factors on Outcomes of Atrial Fibrillation Patients Undergoing Left Atrial Appendage Occlusion Device Implantation.J Interv Card Electrophysiol. 2023 Apr 4; Crossref Scopus (0) Google Scholar). The baseline characteristics were compared using a Pearson χ2 test, Fisher's exact test for categorical variables, and independent samples t-test for continuous variables. A multivariable logistic regression model was utilized to assess the independent association of ≥ 1 PSRFs with outcomes after adjusting for all variables mentioned in Table 1. The statistical analysis was performed using STATA 17.0, and a p<0.05 was considered statistically significant. The research in this study was conducted according to the Helsinki Declaration guidelines on human research.Table 1Baseline characteristics, procedure-related complications, and outcomes stratified by the presence or absence of psychosocial risk factors (PSRFs).Variable no. (%)No-PSRFs (n=6898, 51.6%)≥ 1 PSRFs (n=6470, 48.4%)p-valueFemales20.5%26.1%<0.01Age (SE)63.0 (0.26) yrs60.0 (0.26) yrs<0.01Type of Ventricular TachycardiaIdiopathic ventricular tachycardia37.1%34.5%0.06Structural heart disease related- ventricular tachycardia62.9%65.5%ComorbiditiesValvular heart disease16.0%15.7%0.72Congestive heart failure70.9%74.4%<0.01Chronic pulmonary disease15.7%25.9%<0.01Coronary artery disease62.4%63.1%0.61Prior myocardial infarction29.5%29.6%0.91Obesity17.6%20.8%<0.01Diabetes29.1%29.2%0.94Hypertension68.5%72.6%<0.01Liver disease3.6%4.3%0.11Renal failure22.2%23.2%0.39Peripheral vascular disorder48.0%51.4%0.01Coagulopathy6.9%5.9%0.12History of stroke6.5%7.7%0.09History of percutaneous coronary intervention2.4%2.7%0.39History of coronary artery bypass graft19.5%16.7%<0.01Permanent pacemaker2.8%2.8%0.89Implantable cardioverter defibrillator43.8%47.4%<0.01In-hospital OutcomesVariable no. (%)No-PSRFs (n=6898, 51.6%)≥ 1 PSRFs (n=6470, 48.4%)p-valueAdjusted odds ratio (OR)p-valueIn-hospital mortality3.2%3.2%0.951.07 (0.78-1.48)0.67Any cardiovascular complication*17.7%19.4%0.091.09 (0.94-1.26)0.24Any peripheral vascular complication**2.6%2.7%0.850.98 (0.70-1.36)0.89Any bleeding complication#2.7%3.4%0.381.15 (0.84-1.56)0.38Any pulmonary complication##9.7%11.9%<0.011.14 (0.95-1.36)0.17Any neurological complication$1.2%1.0%0.540.76 (0.48-1.22)0.26Discharge to home82.0%78.5%<0.010.72 (0.63-0.83)<0.0130-day all-cause readmissions10.4%13.4%<0.011.28 (1.08-1.52)<0.0130-day recurrent ventricular tachycardia-related readmissions4.6%5.9%0.031.24 (0.97-1.59)0.0830-day heart failure-related readmissions0.5%0.7%0.381.20 (0.52-2.76)0.66180-day all-cause readmissions22.8%26.4%0.031.22 (1.06-1.47)0.03180-day recurrent ventricular tachycardia-related readmissions8.9%10.8%0.021.53 (1.06-2.20)0.02180-day recurrent heart failure-related readmissions1.2%1.5%0.361.30 (0.44-3.83)0.63*Cardiovascular complications (including cardiac arrest, heart block, myocardial infarction, pericardial effusion, cardiogenic shock, and pericardial effusion requiring intervention)**Peripheral vascular complication (including arteriovenous fistula, pseudoaneurysm, and access site hematoma)#Bleeding complications (gastrointestinal bleeding, blood transfusion, and retroperitoneal bleeding)##Pulmonary complications (including respiratory failure, pneumothorax, pleural effusion, and pneumonia)$Neurological complications (including ischemic stroke, hemorrhagic stroke, and transient ischemic attack) Open table in a new tab *Cardiovascular complications (including cardiac arrest, heart block, myocardial infarction, pericardial effusion, cardiogenic shock, and pericardial effusion requiring intervention) **Peripheral vascular complication (including arteriovenous fistula, pseudoaneurysm, and access site hematoma) #Bleeding complications (gastrointestinal bleeding, blood transfusion, and retroperitoneal bleeding) ##Pulmonary complications (including respiratory failure, pneumothorax, pleural effusion, and pneumonia) $Neurological complications (including ischemic stroke, hemorrhagic stroke, and transient ischemic attack) Our cohort included 13,368 weighted VT ablation procedures, of which 6,470 (48.4%) had ≥ 1 PSRF. Low socioeconomic status was present in 23.7% of patients, psychiatric disease in 22.7% of patients, substance abuse in 14.4% of patients, lack of insurance in 1.4% of patients, and limited cognitive understanding in 1.03% of patients. Baseline characteristics and outcomes are shown in Table 1. On multivariable analysis, the presence of ≥ 1 PSRF was associated with significantly higher odds of 180-day recurrent VT-related readmissions (aOR:1.53; 95% CI: 1.06-2.20; p=0.02). Also, the presence of ≥ 1 PSRF was associated with longer length of stay (aMD: +0.67; 95% CI: +0.16 - +1.19; p=0.01) days and lower odds of routine home discharge (aOR:0.72; 95% CI: 0.63-0.83; p<0.01). Subgroup analysis based on age and sex demonstrated that in patients ≤75 years of age and females, ≥ 1 PSRF was associated with higher odds of 180-day VT-related readmissions. There was no association between PSRFs and procedural complications or readmissions in males and patients >75 years of age. Further analysis was performed to identify the domain of PSRFs associated with worse outcomes in patients undergoing VT ablation. On multivariable analysis, only the presence of psychiatric disease (aOR:1.65; 95% CI: 1.23-2.67; p=0.02) was associated with higher odds of 180-day VT-related readmissions. There is limited data examining the impact of PSRFs on outcomes in patients undergoing VT ablation and to our knowledge this is the first study to address this critical topic using a large national claims-based database. Our study demonstrated that PSRFs are present in a significant proportion of patients undergoing VT ablation and PSRFs, specifically psychiatric disease, are associated with increased odds of VT recurrence. Studies have demonstrated complex associations between emotional states and cardiovascular disease risk with both depression and anxiety being independently associated with an increased risk of adverse cardiovascular outcomes, likely mediated through dysregulation of the autonomic nervous system due to a state of chronic stress in these individuals (5Havranek E.P. Mujahid M.S. Barr D.A. et al.Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association.Circulation. 2015 Sep 1; 132: 873-898Crossref PubMed Scopus (809) Google Scholar). Additionally, studies have shown that a considerable proportion of patients with psychiatric disease have a low socioeconomic position, low social capital, and poor residential environment with limited access to medical care which could affect medication compliance and follow-up care, potentially leading to increased recurrence (5Havranek E.P. Mujahid M.S. Barr D.A. et al.Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association.Circulation. 2015 Sep 1; 132: 873-898Crossref PubMed Scopus (809) Google Scholar). Another potential explanation for these findings could be the higher burden of comorbidities in patients with PSRFs which could potentially have led to these worse outcomes. Limitations of our study include the lack of patient-level data verification due to the use of a de-identified database, the possibility of coding errors, the lack of data on procedural details, and the lack of a universal definition of PSRFs. Furthermore, although we adjusted for underlying comorbidities, given the nature of the non-randomized analysis, unmeasured confounders could still exist. In conclusion, our data suggest an association between PSRFs and all-cause and VT-related re-admissions, as well as higher hospital resource utilization in patients undergoing VT catheter ablation. These hypothesis-generating data should be examined in large clinical prospective studies.