A review paper published in JACC: Clinical Electrophysiology explores the potential mechanisms linking stress and atrial fibrillation (AF), and the possible uses of stress reduction in the management of the condition.
Stress has been linked with poor health outcomes, though the exact mechanism remains poorly defined. Psychological stress is recognised as a contributing factor in both initiation and heightening of AF. The diagnosis of AF is often associated with increased anxiety, psychological distress and suicidal ideation.
According to the authors of the study in JACC: Clinical Electrophysiology, there is significant global variation in people reporting psychological stress, but on average it is reportedly experienced by one in three people. The authors define stress “as the perception of internal or external demands which exceeds one’s aptitude for an adaptive response.” Reported stress levels have been on the rise annually with the COVID-19 pandemic leading to an even larger increase in self-reported psychological distress.
“We are seeing that psychological stress and even negative emotions are associated with initiation and potentiation of AF,” said senior study author Peter Kistler, head of clinical electrophysiology research at Baker Heart and Diabetes Institute and Head of Electrophysiology at the Alfred Hospital, Melbourne, Australia. “By recognising stress as a potentially modifiable risk factor in these patients builds on a more holistic approach to AF management. As such, targeted stress reduction may improve symptom perception and outcomes for patients with AF.”
The researchers examined studies on the role of stress in AF, as well as modifying traditional AF risk factors such as diet, alcohol cessation and exercise. The review also focuses on the bidirectional nature of the AF and stress relationship. The study authors looked at the role of acute and chronic stress in inducing AF; the role stress plays on physiologically changing the heart; gender differences in response to stress; as well as how to measure stress, which is often subjective and self-reported.
“We also have to better consider the bidirectional nature of stress and AF. More and more studies are showing it goes both ways,” Kistler said. “Stress begets AF and AF begets stress. When we are managing AF patients, clinicians tend to focus on the physical symptoms of AF and not fully consider both baseline and evolving mental health consequences of having a heart rhythm disorder.”
According to the review, stress and negative emotions are often accompanied by modifiable risk factors. For example, individuals experiencing chronic stress often report higher numbers of smoking, alcohol consumption, weight gain and physical inactivity. The risk factors contribute to worsening AF symptoms in patients. Potential treatment options to reduce stress as part of AF management included further study into anxiolytic and antidepressant therapy, mindfulness-based stress reduction and yoga.
“Clinicians must recognise and address the psychosocial implications of an AF diagnosis by providing patient education and reassurance in tandem with conventional interventions to reduce symptoms and improve quality of life,” Kistler said. “By considering the impact of stress on illness perception, recognising and mitigating stress may reduce symptoms and distress, enhance resilience and modify health behaviours to improve outcomes.”
The authors conclude further research is needed to establish standardised methods of detecting and quantifying stress, while randomised trials are needed to better evaluate the impact of stress reduction on AF management.