Factors that influence marital satisfaction in men with a heart rhythm disorders

Abstract

Background

A diagnosis of a cardiac arrhythmia can affect marital relations and diminish libido and satisfaction with a patient’s sex life. The aim of the study was to assess the factors that affect marital satisfaction in men with an arrhythmias who had qualified for cardiac pacemaker implantation.

Methods

The study included 103 men (aged 58.28 ± 8.72) with recognized heart rhythm disorders who were hospitalized in Department of Electrocardiology. The Hospital Anxiety and Depression Scale (HADS), the International Erectile Function Index (IIEF) and the Index of Marital Satisfaction (IMS) were used in this research.

Results

The greater the severity of the anxiety (r = 0.2492, p = 0.011) and depression symptoms (r = 0.3735, p = 0.000), the less satisfied a patient was with the relationship. An analysis showed that depression (p = 0.000), sexual desire (p = 0.001), overall satisfaction (p = 0.009), erectile function (p = 0.0162) and intercourse satisfaction (p = 0.026) are important predictors of marital satisfaction. Only sexual desire was an important predictor of marital satisfaction in patients with sinus node dysfunction, while the depression, sexual desire and overall satisfaction results were predictors in patients with atrioventricular blocks.

Conclusion

Anxiety and depression symptoms affect the assessment of marital satisfaction in men with a heart rhythm disorder. Different factors influence marital satisfaction for different heart rhythm disorders.

Keywords:

• Cardiac arrhythmias
• marital satisfaction
• anxiety
• depression
• sex life

Introduction

Marital satisfaction is shaped by the perceived quality of the interaction between individuals. The determinants of the level of marital satisfaction include the level of happiness of a couple associated with their relationships, feelings about marriage and factors related to sexual functioning and emotional status [1–3]. Sexual dysfunction affects at least half of patients suffering from depression. The main problems are a reduced interest in sex, reduced sexual desire and a lack pleasure from having sex. The decrease in sexual activity and desire is primarily associated with the main symptoms of this disease and usually goes away as an individual feels better during treatment. People who suffer from the symptoms that are associated with anxiety have a significantly diminished satisfaction with their sex life. Their interest in sex decreases (decreased desire), difficulties arise during sexual intercourse (excitement disorders) and there may be a premature or delayed orgasm. These cause problems in their relationship with their partner, which can sometimes even result in the complete cessation of sexual activity and a reduced satisfaction with the relationship [4–6].

Health problems, especially life-threatening ones, particularly expose susceptible patients to depression, relationship disorders, etc. [7–9]. Potentially fatal cardiac arrhythmias are examples of such disorders. Sinus node dysfunction (SND) and AV blocks (AVB) are the underlying pathologies for the majority of patients for whom the implantation of a cardiac pacemaker is the only method of treatment. Mortality in sinus node dysfunction without treatment is about 2% per year, meanwhile in atrio ventricular blocks vary between 9 – 16% per year. While the main symptom of both diseases is bradycardia (heart rhythm < 40/min), some patients may also have severe symptoms such as syncope [10]. However, there are differences between the two diseases – in AVB, the symptoms are sometimes more sudden, unexpected and dangerous, while the SND symptoms are usually more chronic, which enables a patient to become accustomed to them. Although it was previously documented that the implantation of a cardiac pacemaker improves the quality of life both in patients with AVB and SND, anxiety/depression become more intense in patients with AVB [11]. Accordingly, this can result in disturbances in the relationship with a partner. Arrhythmias and indications for cardiac pacemaker (or cardioverter-defibrillator) implantation can have a significant impact on an individual’s sex life, relationship with a partner, which can lead to depression [12–14]. In patients with symptomatic cardiac arrhythmias, the implantation of an antiarrhythmic device may affect marital relations and reduce libido and the satisfaction with their sex life.

The aim of the study was to assess the factors that affect marital satisfaction in men depending on the type of arrhythmia (sinus node dysfunction or AV blocks), which were the main reason that they qualified for cardiac pacemaker implantation.

Materials and methods

Sample and procedure

The study was conducted on 103 men (aged 58.28 ± 8.72) with recognized heart rhythm disorders who were hospitalized in Department of Electrocardiology. The patients that were included in the study were divided into two groups depending on the type of heart rhythm disorder:

SND group – sinus node dysfunction (SND) − 41.75%; (aged 59.35 ± 9.35);

AVB group – atrioventricular blocks (AVB) − 58.25%; (aged 57.52 ± 8.24).

The patients were divided into the groups according to the guidelines of the European Society of Cardiology. A diagnosis of the cardiac arrhythmia that had qualified them for pacemaker implantation, sexual activity, marital status or the actual presence of a permanent partner and being 18 years were the criteria for inclusion in the study. Patients with recognized depression, heart failure, the coexistence more than one arrhythmia disease, and those who refused to participate in the study were excluded. The study also did not include patients with a previously diagnosed sexual dysfunction or those who were undergoing therapy.

Measurement tools

The sociodemographic and clinical characteristics of the studied patients including their age, place of residence, cardiovascular risk factors, education and occupational activity are presented in Table 1. Three well-recognized international research tools were used in this trial.

Table 1. The sociodemographic and clinical characteristics of the participants.

Parameter	Entire group	SND	AVB	p Value
Age	58.28 ± 8.72	59.35 ± 9.35	57.52 ± 8.24	0.2954
Place of residence – city (%)	92.23	95.35	90.00	0.3127
Alcohol consumption (%)	12.62	20.93	6.66	0.0644
Smoking (%)	26.21	27.91	25.00	0.7402
Hypertension (%)	50.48	58.14	45.00	0.1184
Education (%)
Primary	57.28	39.53	70.00
Secondary	23.30	27.91	20.00	0.0035
Higher	19.42	32.56	10.00
Occupational activity – Working (%)	31.07	25.58	35.00	0.3083
IIEF
IIEF (overall)	41.41 ± 7.36	43.35 ± 7.41	40.02 ± 7.06	0.0227
Erectile function	17.36 ± 4.84	18.28 ± 4.33	16.70 ± 5.11	0.1029
Orgasmic Function	4.61 ± 2.01	4.98 ± 2.02	4.33 ± 1.98	0.1097
Sexual desire	5.96 ± 1.99	6.02 ± 1.88	5.92 ± 2.08	0.7901
Intercourse satisfaction	7.82 ± 2.45	8.49 ± 2.40	7.35 ± 2.39	0.0195
Overall satisfaction	5.66 ± 2.61	5.58 ± 2.63	5.72 ± 2.62	0.7971

SND: sinus node dysfunction; AVB: atrioventricular block; IIEF: International Index of Erectile Function.

The Hospital Anxiety and Depression Scale (HADS) was designed 30 years ago by Zigmond and Snaith to measure anxiety and depression in the general medical population of patients – this tool is used to assess the occurrence of the symptoms of anxiety and depression. The questionnaire contains 14 questions for the two conditions – anxiety and depression. Each question is rated on a scale of 0–3 points. The scoring range is the same for both anxiety and depression. A score of 0–7 indicates a normal state, 8–10 indicates the possibility of anxiety or depression and a score of 11–21 points corresponds to a recognition OR diagnosis of the disease. The higher the number of points, the greater the severity of the symptoms. The HADS enables anxiety and depression to be assessed in both hospitalized patients and outpatients. The HADS scale was translated and adapted to the Polish conditions has proven to be a reliable research tool for assessing depression and anxiety [15]. The Cronbach’s alpha reliability coefficient for anxiety is 0.7727 and for depression, it is 0.8008 and both are acceptable coefficients.

The International Erectile Function Index (IIEF), which is a five-level self-assessment of all areas of male sexual function for the previous four weeks, was also used. The greater the number of points, the fewer problems an individual has with their sexual functioning. The IIEF questionnaire includes 15 items that are grouped into 5 collective domains (subscales), which describe: I – Erectile Function (six questions) – the maximum possible score is 30 points and a score below 25 points is considered to be abnormal; II – Orgasmic Function (two questions) – the maximum number of points is 10 and a score below 9 points is considered to be abnormal; III – Sexual Desire (two questions) – the maximum possible score is 10 points and a score below 9 points is considered to be abnormal; IV – Intercourse Satisfaction (three questions) – the maximum possible score is 15 points and the cutoff value is 13 points and V – Overall Satisfaction (two questions) – the maximum possible score is 10 points and a score below 9 points is considered to be abnormal [16]. Cronbach’s alpha reliability coefficient for this test was 0.8109.

The Index of Marital Satisfaction (IMS) is a 25-element scale that enables the degree, severity or magnitude of the problems that an individual’s spouse or partner perceives in the marital relationship to be determined. The scale was designed by Hudson and the emphasis is on current problems that have decreased marital satisfaction. The final result is obtained by summing the direct (points 2, 4, 6, 7, 10, 12, 14, 15, 18, 22, 24, 25) and the reverse (1, 3, 5, 8, 9, 11, 13, 16, 17, 19, 20, 21, 23) results in order to obtain a raw test result. The IMS is obtained by subtracting 25 points from the total result. A score below 30 indicates satisfaction with the relationship, while a lower total score on the IMS indicates greater satisfaction with the marital relationship [17,18]. Cronbach’s alpha reliability coefficient for the IMS tool was 0.7013.

Ethical Considerations

The research was approved by the Bioethics Committee of the Medical University of Silesia, number KNW/0022/KB/2019. The investigation conformed to the principles outlined in the Declaration of Helsinki and recommendations of Good Clinical Practice. Participation in this study was anonymous and voluntary and participants had the possibility of withdrawing at any stage of the study. The dignity and rights of the participants were respected at all times.

Statistical Analysis

The obtained data were subjected to statistical analysis, p < 0.05 was assumed as a significant statistical value. Student’s t-test was used for comparison quantitative data about normal distribution and Chi square the test was applied to nonparametric data. Pearson’s correlation coefficient r was used to correlate IMS with male sexual function, anxiety and depression. To assess whether the parameters that were analyzed were predictors of the dependent variables, multiple regression stepwise analysis was used. All of the calculations were done using the Polish version of Statistica (StatSoft Inc., Tulsa, OK).

Results

The sociodemographic and clinical characteristics including the average results of the International Index of Erectile Function (IIEF) domains of the studied patients are presented in Table 1. The median age of the initiation of sexual relations in the studied men was 18; for the patients in the SND group, it was 17 years, while for the patients in the AVB group was 18 years. All of the men that were included in the study stated that they were sexually active. Only 49.5% of the patients said they were satisfied with their relationship. The average value of satisfaction with their relationship was 31.42 ± 5.27. There were no statistically significant differences in the IMS that were dependent on the type of arrhythmia (SND: 30.44 ± 4.89 vs. AVB: 32.12 ± 5.46; p = 0.113).

Correlations

Some correlations were found between marital satisfaction and the symptoms of anxiety and depression. The greater the severity of the anxiety symptoms, the less satisfied a patient was with the relationship (r = 0.2492, p = 0.011). A similar correlation was found between the satisfaction with the relationship and the severity of depression symptoms. The greater the severity of depression symptoms, the less satisfaction there was with the relationship (r = 0.3735, p = 0.000). An identical correlation was found among the patients with diagnosed AVB (r = 0.4617, p = 0.000). No such correlation was found among the patients with SND (r = 0.1826, p = 0.241). No correlation was found between anxiety and depression and sexual functioning in any domain. An analysis of the correlation between marital satisfaction and the domains of sexual function showed that sexual desire correlated with marital satisfaction. The greater the sexual desire, the greater the marital satisfaction (r= −0.2340, p = 0.012). The details are presented in Table 2.

Table 2. Correlation between the IMS, anxiety and depression and all areas of male sexual function.

	IMS entire group	IMS SND group	IMS AVB group
Anxiety	r = 0.2492, p = 0.011	r = 0.0106, p = 0.946	r = 0.4150, p = 0.001
Depression	r = 0.3735, p = 0.000	r = 0.1826, p = 0.241	r = 0.4617, p = 0.000
IIEF	r= −0.0148, p = 0.882	r = 0.0617, p = 0.694	r= −0.0056, p = 0.966
Erectile function	r = 0.0945, p = 0.342	r = 0.2141, p = 0.168	r = 0.0738, p = 0.575
Orgasmic Function	r = 0.0484, p = 0.627	r = 0.0751, p = 0.632	r = 0.0756, p = 0.566
Sexual desire	r= −0.2340, p = 0.017	r= −0.2596, p = 0.093	r= −0.2173, p = 0.095
Intercourse satisfaction	r= −0.1760, p = 0.075	r= −0.1298, p = 0.407	r= −0.1560, p = 0.234
Overall satisfaction	r = 0.0895, p = 0.368	r = 0.0680, p = 0.665	r = 0.0987, p = 0.453

AVB: atrioventricular block; IIEF: International Erectile Function Index; SND: sinus node dysfunction.

Regressions

A multiple regression model using the stepwise input method was used. The predictors were all of the areas of male sexual function, anxiety and depression. The dependent variable was marital satisfaction. The model was statistically significant and explained 29% of the observed variance in the dependent variable (p = 0.000, R2 = 0.2906). The analysis showed that depression (p = 0.000), sexual desire (p = 0.001), overall satisfaction (p = 0.009), erectile function (p = 0.016) and satisfaction with intercourse (p = 0.026) were important predictors of the dependent variable. The details are presented in Table 3.

Table 3. Regression summary for a/the dependent variable: IMS all group.

	Beta	SE of Beta	B	SE of B	t(97)	p Value
Intercept			29.02578	3.025616	9.59335	0.000
Depression	0.349880	0.086604	0.47445	0.117438	4.04000	0.000
Sexual desire	−0.311445	0.091557	−0.82501	0.242532	−3.40167	0.001
Overall satisfaction	0.266797	0.100039	0.53792	0.201701	2.66692	0.009
Erectile function	0.255777	0.104611	0.27842	0.113870	2.44502	0.016
Intercourse satisfaction	−0.221524	0.098016	−0.47558	0.210424	−2.26009	0.026

Notes: R = 0.5391, R2 = 0.2906, adjusted R2 = 0.2541, F = 7.95, p = 0.000. IMS: Marital Satisfaction Index.

The multiple regression model in the group of patients with SND in which the predictors were all of the areas of male sexual function, anxiety, depression and the dependent variable was marital satisfaction was statistically significant and explained 23% of the observed variance in the dependent variable (p = 0.000; R2 = 0.2275). The analysis showed that only sexual desire was an important predictor dependent variable. The details are presented in Table 4.

Table 4. Regression summary for dependent variable: IMS in SND group.

	Beta	SE of Beta	B	SE of B	t(97)	p Value
Intercept			29.34142	4.587907	6.39538	0.000
Sexual desire	−0.337446	0.155726	−0.87649	0.404486	−2.16692	0.037
Depression	0.202767	0.148471	0.29606	0.216786	1.36570	0.181
Erectile function	0.276492	0.158420	0.31213	0.178841	1.74531	0.089
Overall satisfaction	0.237809	0.158138	0.44237	0.294165	1.50381	0.141
Intercourse satisfaction	−0.211888	0.152347	−0.43116	0.309999	−1.39083	0.173

Notes: R = 0.4769, R2 = 0.2275, adjusted R2 = 0.1231, F = 2.17, p = 0.0000.

SND: sinus node dysfunction; IMS: Marital Satisfaction Index.

When the dependent variable was marital satisfaction in the group of patients with AVB, it was significant and it explained 34% of the observed variance in the dependent variable (p = 0.000; R2 = 0.3404). Multiple regression analyses showed that the parameters that exerted a significant independent effect on the level of marital satisfaction were depression, sexual desire and overall satisfaction. The details are presented in Table 5.

Table 5. Regression summary for dependent variable: IMS in AVB group.

	Beta	SE of Beta	B	SE of B	t(97)	p Value
Intercept			25.86346	4.500153	5.74724	0.000
Depression	0.444408	0.115071	0.57205	0.148122	3.86202	0.000
Sexual desire	−0.276232	0.119811	−0.72602	0.314900	−2.30557	0.025
Overall satisfaction	0.334463	0.142375	0.69595	0.296253	2.34917	0.022
Erectile function	0.277727	0.145031	0.29673	0.154956	1.91494	0.061
Intercourse satisfaction	−0.139115	0.138955	−0.31655	0.316190	−1.00115	0.321

Notes: R = 0.5834, R2 = 0.3404, adjusted R2 = 0.2793, F = 5.57, p = 0.0000.

AVB: atrioventricular block; IMS: Marital Satisfaction Index.

Discussion

It is assumed that relationships in a marriage can affect other aspects of life such as job satisfaction, health satisfaction and mental health. The positive behaviors that directly affect marital satisfaction include mutual acceptance, a spouse’s approval and negotiating ideas. On the other hand, the most visible negative behaviors that limit marital satisfaction are blame, criticism and pressure. From the point of view of both men and women, the most common problems that are associated with marriage are communication, sexuality, poor health and family [19–21]. Izdebski et al. [22] showed a strong relationship between the quality of one’s sex life and marriage. At the same time, the inability to have sex adversely affects a relationship, one’s relationship with their partner, self-esteem and family relationships. In a study by Byrne et al. [17], about a third of the participants reported that sex had changed for the worse, and about half of this group said it was a serious problem for them. The reasons for a decreased sex life after being diagnosed with heart disease included problems of tiredness, a lack of energy, a loss of interest in sex and anxiety. In relation to satisfaction with the relationship, more than 70% of the patients were very happy with the physical, emotional and emotional aspects of sex. The authors found no link between a deterioration of sexual functioning and relationship satisfaction or between reporting sexual problems and relationship satisfaction. Marital satisfaction can also be also deeply affected by diseases, especially those that are potentially life threatening. Examples of such diseases are cardiac arrythmias. In our study, satisfaction with the relationship was affected by sexual function and all of its components as well as with the occurrence of depression symptoms. Sexual functioning and depression affected the satisfaction of patients with atrioventricular blocks; however, there was no such relationship among the patients with sinus node dysfunction. In patients with sinus node dysfunction, only sexual desire affected the satisfaction with the relationship. Patients with AV blocks have a greater severity of sexual dysfunction than patients with sinus node dysfunction [13]. An important question arises – why is the status of a marriage affected differently depending on the type of arrhythmia. Finding the answer is not an easy task. In our opinion, the occurrence of an impairment of sexual function can be explained by the greater impact of these disorders on the assessment of marital satisfaction. Low levels of marital satisfaction may be associated with depression and anxiety disorders. Research indicates that marital satisfaction can be predicted based on the level of anxiety or depression of one’s spouse. Anxiety and depression often occur in patients with known chronic diseases. Studies by Mlynarski et al. have indicated that patients with atrioventricular blocks suffer from anxiety and depression more often than patients with sinus node dysfunctions. In our study, we also proved that the symptoms of depression in patients with atrioventricular blocks affect the assessment of marital satisfaction [11,23–25]. A satisfying sex life is the basis for maintaining a relationship and strengthening partnerships. In addition, couples with a high level of mutual marital satisfaction have a lower level of stress, a higher level of happiness and a greater ability to cope with adverse life situations [26,27].

The results of the research of Culha et al. [28] demonstrated that both Castelli’s risk index CR-1 (total cholesterol/HDL) and AIP (atherogenic index of plasma) have a positive correlation with the severity of erectile dysfunction. The authors believed that patients with higher CR-1 and AIP values were likely to have a more severe erectile dysfunction in the future. Those results can be connected with those presented here and can also be used for patients with cardiac arrythmias. Some male patients with diagnosed arrhythmias suffer from anxiety and depression, which can result in dissatisfaction with the marriage. Our results suggest that sexual desire was affected in both of the analyzed groups of patients with heart rhythm disorders. It seems that sexually active patients that are qualified for cardiac pacemaker implantation may benefit from early psychological support. Urologists who diagnose and treat erectile dysfunction and all general aspects of men’s health can also play an important role including for men with cardiac arrythmias [29]. Increasing patient and provider awareness, changing lifestyle behaviors and promoting self-care practices can also be useful for supporting male patients that have cardiac arrythmias [30]. An interesting idea was also presented by Kalka D et al. [31] 17 who had been examined 417 hospitalized in the cardiology departments patients and underwent cardiac rehabilitation. According to their results, the cardiac patients with erectile dysfunction knew more about the risk factors for cardiovascular diseases than those for sexual dysfunction. The authors concluded that information about the negative impact of the risk factors on sexual health should be incorporated into the education programs for promoting healthy lifestyles. Further research, including multi-center studies on a larger group of patients, seems to be necessary to confirm our results.

Limitation of the study

Our study also had some limitations. The most significant was the relatively small number of enrolled patients and the fact that they all came from one center. The number of available, validated and reliable tools that can be used is also limited. It should also be mentioned that the patients, especially before the pending implantation of a pacemaker, are often reluctant to answer these types of questions. Moreover, there may be cultural differences that can affect the results in different countries or geographical regions. We hope that our results will lead to a wider discussion in the scientific community about the need for changes in the care of patients with cardiac arrhythmias, who are being treated with electrostatic stimulation.

Conclusion

Anxiety and depression symptoms affect the assessment of marital satisfaction in men with heart rhythm disorders. Only sexual desire was an important predictor of marital satisfaction in patients with a sinus node dysfunction, while depression, sexual desire, and overall satisfaction were predictors in patients with atrioventricular blocks.

Disclosure statement

No potential conflict of interest was reported by the author(s).