Targeted stress reduction may improve AF symptoms, outcomes
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Efforts to mitigate acute and chronic stress could help reduce atrial fibrillation-related symptoms and improve AF outcomes, though more data are needed to evaluate best practice for stress reduction, researchers reported.
In a literature review published in JACC: Clinical Electrophysiology, researchers highlighted the bidirectional relationship between psychological stress and AF, outlined potential mechanisms behind the association and the explored role of stress as a modifiable risk factor.
“We are seeing that psychological stress and even negative emotions are associated with initiation and potentiation of AF,” Peter Kistler, MBBS, PhD, head of clinical electrophysiology research at the Baker Heart and Diabetes Institute and head of electrophysiology at the Alfred Hospital in Melbourne, Australia, said in a press release. “Recognizing 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.”
Mechanisms linking AF, stress
Psychologic stress and negative emotions can worsen AF symptom severity, further accentuating negative perceptions of well-being and quality of life, the researchers wrote. Emotional or physical exhaustion is a reported trigger for AF in up to 30% of episodes, according to the review; PTSD was associated with a 13% increased risk for incident AF among military members.
“Stress begets AF and AF begets stress,” Kistler said in the release. “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.”
Stress and negative emotions are often accompanied by modifiable risk factors, such as smoking, alcohol consumption, weight gain and physical inactivity, which contribute to worsening AF symptoms. However, stress perception is subjective and relies heavily on self-reported measures. The researchers wrote there is no universally accepted “gold standard” for measuring stress; a lack of uniformity in measuring stress in previous studies hinders direct comparisons of stress quantification.
“Prospective studies are lacking, limiting our understanding of the precise relationship between AF and stress,” the researchers wrote. “Future studies could establish standardized methods of detecting and quantifying stress, and randomized studies are needed to better evaluate the impact of stress reduction on AF management.”
Lifestyle as ‘fourth pillar’
Cultivating resilience and targeted stress reduction, as well as lifestyle modification, may have a role in modifying stress perception among a range of CV conditions, including AF, the researchers wrote.
“Recently, lifestyle modification has emerged as the fourth pillar of AF management, with stress reduction a potential reversible risk factor and future target for intervention,” the researchers wrote.
The review highlighted several nonpharmacologic approaches to reducing stress. Yoga has been shown to decrease BP, improve endothelial function and reduce inflammation, which may indirectly reduce AF recurrence. A nonrandomized study demonstrated 3 months of daily Iyengar yoga significantly reduced symptomatic and asymptomatic AF episodes and improved self-reported anxiety, depression and quality of life among 49 participants with paroxysmal AF.
Mindfulness-based stress reduction, which promotes strategies for emotional self-regulation, was shown to reduce BP and perceived negative emotions, but has not been evaluated in the AF population.
“Small studies suggest that acupuncture may reduce AF recurrence and burden in paroxysmal and persistent AF, although this has not been prospectively validated,” the researchers wrote.
There is “limited evidence” to support anxiolytic or antidepressant therapy in AF management and more data is needed; there are no randomized controlled trials on the use of selective serotonin reuptake inhibitors among adults with AF.
“Clinicians must recognize 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 in the release. “By considering the impact of stress on illness perception, recognizing and mitigating stress may reduce symptoms and distress, enhance resilience and modify health behaviors to improve outcomes.”
Perspective
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John D. Day, MD, FHRS
Psychological stress has long been thought to be a possible trigger of AF, and the association appears to be strong among women. But men aren’t immune. Neither are cardiologists — who it can be said to have one of the most stressful jobs in the world. In our AF clinic, we have treated countless doctors over the years with AF as well as innumerable CEOs, lawyers, accountants, politicians, athletes, celebrities and others who have come to see us for AF treatment due in large part to the enormous stresses they are under.
What kinds of challenges can create stress that triggers AF? Work-related stress is a common AF trigger we see many times every day, particularly if it one is in a toxic work environment or subject to long working hours. Family stress, whether it be financial, an off-course child, a relationship breakup or even the death of a loved one can all quickly send hearts into AF.
When combating stress, we need to remember that not all stress can be removed and that some stress is good — and remember that, good or bad, there are parts of life we cannot always control. Then, stress loses its power to ruin our lives. This is not an easy conceptual shift to make. It takes time and practice. But given how easily stress can trigger AF and knowing that perception is a powerful force when it comes to stress, it is absolutely worth the effort.
If yoga does not put your AF into remission, then consider other forms of mindful engagement like meditation, tai chi, prayer, nature walks or daily exercise, which can be just as effective. I do not personally have AF; however, I am not immune to stress. My own work and family stressors can sometimes be overwhelming at times. But if I can carve out the time to go on a run, ski or mountain bike in nature with a family member, the stresses I am feeling at the time don’t seem so big after all.
The key for me, as well as my patients, is to turn life’s distress into “eustress,” which is a healthy dose of moderate psychological stress that is beneficial for us and keeps us moving forward.
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