The Mind-Atrial Fibrillation Connection

Talking therapy for AFib management

I apologise for the brief hiatus in emails- I was under a self-imposed lockdown whilst writing up and completing my PhD in Atrial Fibrillation. The hard work has paid off and Thesis now submitted. After a period of embargo I look forward to sharing the trial results here soon. Sincere thanks to all the participants who patiently gave their time, samples and data to the cause. And so from this week, I endeavour to resume normal service here!

To the new subscribers- welcome. Each week I cover a FAQ that is important to patients with Atrial Fibrillation or explore interesting AFib related research. If you have any questions or topics you would like covered, please get in touch!

A lingering topic from 2024, was the association between mood and AFib. Low mood worsen symptoms, which leads one to ask…can improving mental state and wellbeing treat Atrial Fibrillation?

Swedish researchers tested this hypothesis in an elegant study in patients with paroxysmal (intermittent) Atrial Fibrillation using a non-pharmacological treatment, cognitive behavioural therapy (CBT), colloquially known as ‘talking therapy’.

CBT typically involves:

Identifying negative or unhelpful thought patterns.
Learning to challenge and reframe these thoughts.
Developing coping mechanisms for managing stress and negative emotions.

The investigators designed a bespoke 10-week course of CBT delivered by a trained therapist to focus on fear and hypervigilance toward cardiac-related symptoms, the fear of recurrent AF episodes, and AF-related avoidance of physical and social activities. This intervention was called AF-CBT.

65 patients underwent AF-CBT. Of note, 32% reported a depressed mood and 25% reported anxiety disorder at time of enrolment. AF-CBT led to a significant improvement in reported AF symptom severity, with a mean improvement of 21 points in the AFEQT score, a validated measure of symptom severity out of 100. To put this into context, catheter ablation has been shown to improve symptom severity by 12 points (at 12 months).

However, there are several considerations to make before we prescribe AF-CBT to all our AF patients:

The authors reported the improvement at 3 months post-intervention, the results figure in the paper does show the symptom score trends down after an immediate peak post-treament, although it remained higher at 12-months after CBT than it was before the intervention. How the symptom severity progresses after this time point is unknown, and the effect of ‘top-up’ CBT sessions wasn’t assessed.

The blue line and shaded region represents the change in AF symptom severity in participants undergoing AF-CBT. The change represents improvement compared to the symptom score before CBT. The score is significantly better after CBT, although it appears to trend downwards over time. Image adapted from here

All participants had paroxysmal Atrial Fibrillation, so we do not know how it would affect patients who had persistent Atrial Fibrillation or patients who had failed other treatments like catheter ablation (9% of the AF-CBT group had had prior catheter ablation despite having had AF for a mean duration of 6 years). This would be a really interesting group of patients to study because for patients in whom conventional treatment options fail, alternative treatment approaches can offer greatest benefit.

Finally, there is a likely placebo effect at play. Participants may be inclined to report improved simply after repeated appointments with a healthcare team and time invested into the treatment plan. To truly demonstrate benefit, the effect of AF-CBT should be compared to an alternative treatment and the effect on more objective outcome measures should be determined.

Luckily, that’s what the authors did.

In November 2024, the authors reported the effect of AF-CBT on objective measures. This included the effect on patient activity levels using step trackers, the effect on sleep using sleep monitors. The effect on AFib burden i.e. the time a participant spent in AFib before versus after AF-CBT was also measured using heart rhythm monitors. Furthermore, they compared the effect of AF-CBT on these parameters to the effect of conducting sessions delivering AF education, without any CBT. This comparator group would serve as a control group to determine whether any benefits were simply attributable to the face-to-face time the patient had with the healthcare professionals rather than the CBT itself.

The authors reported no significant difference in activity levels, sleep duration or AF burden after AF-CBT compared to before it.

The table shows that there was no significant difference in HRV (heart rate variability), AF burden (the time in AF), the daily stepcount, activity questionnaire (IPAQ) or sleep duration before CBT versus afterwards. 'NS' in the p-value row reflects that the statistical difference between pre- and post- was non-significant. The final column shows that the reported insomnia severity did reduce after CBT.

The authors felt the lack of improvement in activity and sleep was because the participants were active (~8000 steps/day) with good sleep (~8 hours) at enrolment so there was little room for improvement. Alternatively it could be due to reporting bias or a placebo effect which means patients may be reporting that they felt better, reflected by the improved symptoms in the AFEQT score, but no change in the objective parameters. I would have been quite surprised if there was a reduction in their AF burden using CBT alone. Although theoretically it could have affected the autonomic nervous system (the internal hormonal balance driving our fight or flight response), AF is a progressive disease that is associated with structural and electrical changes in the heart.

So what is the take away from this?

There are undisputed benefits of CBT, especially in individuals with low mood or anxiety. There is a significant fear and anxiety component associated with AF, especially when there is poor education and understanding of the condition which can lead to fearful behaviours such as avoidance, inactivity and isolation. Understanding AF is a critical part of its management and can reduce symptom severity as demonstrated here in the AF-CBT study.

In an ideal scenario each patient would have unlimited access to healthcare professionals to present concerns, discuss their symptoms and develop an understanding of their condition. Whilst healthcare systems globally develop systems to holistically support patients in this way, the BartsAF blog can serve as an interim solution ;)

Read the full articles here:

Särnholm J, Skúladóttir H, Rück C, Axelsson E, Bonnert M, Bragesjö M, Venkateshvaran A, Ólafsdóttir E, Pedersen SS, Ljótsson B, Braunschweig F. Cognitive Behavioral Therapy Improves Quality of Life in Patients With Symptomatic Paroxysmal Atrial Fibrillation. J Am Coll Cardiol. 2023 Jul 4;82(1):46-56. doi: 10.1016/j.jacc.2023.04.044. PMID: 37380303.

Skúladóttir H, Särnholm J, Ólafsdóttir E, Arnardóttir ES, Hoppe K, Bottai M, Ljótsson B, Braunschweig F. Cognitive Behavioral Therapy for Paroxysmal Atrial Fibrillation: Heart Rate Variability, Physical Activity, and Sleep. JACC Adv. 2024 Sep 27;3(11):101289. doi: 10.1016/j.jacadv.2024.101289. PMID: 39399519; PMCID: PMC11470246.