Catheter ablation, but not medical therapy, improves anxiety and depression symptoms in AF
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Key takeaways:
- In patients with atrial fibrillation, catheter ablation reduces anxiety and depression symptoms better than medical therapy.
- The ablation group was less likely to have severe psychological distress at 12 months.
In patients with symptomatic atrial fibrillation, catheter ablation improved psychological symptoms of anxiety and depression compared with medical therapy, according to results of the REMEDIAL trial.
The researchers conducted a randomized trial of 100 patients with symptomatic AF (mean age, 59 years; 32% women; 54% with paroxysmal AF) treated at two centers in Australia from June 2018 to March 2021 to compare catheter ablation to medical therapy for effects on psychological symptoms of anxiety and depression.
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All patients from the ablation group had successful pulmonary vein isolation, the researchers wrote in JAMA.
The primary outcome was Hospital Anxiety and Depression Scale (HADS) score, in which a higher score reflects more anxiety and depression and a score of more than 15 represents severe psychological distress; 32% of the cohort had severe psychological distress at baseline.
The HADS score was lower in the catheter ablation group than in the medical therapy group at 6 months (8.2 vs. 11.9; P = .006) and at 12 months (7.6 vs. 11.8; between-group difference, –4.17; 95% CI, –7.04 to –1.31; P = .005), Jonathan M. Kalman, MBBS, PhD, professor of medicine at The Royal Melbourne Hospital in Melbourne, Australia, and colleagues wrote.
The prevalence of severe psychological distress was lower in the catheter ablation group at 6 months (14.2% vs. 34%; P = .02) and at 12 months (10.2% vs. 31.9%; P = .01) compared with the medical therapy group, according to the researchers.
The following scores were also lower in the catheter ablation group compared with the medical therapy group:
- Anxiety HADS score at 6 months (4.7 vs. 6.4; P = .02);
- Anxiety HADS score at 12 months (4.5 vs. 6.6; P = .02);
- Depression HADS score at 3 months (3.7 vs. 5.2; P = .047);
- Depression HADS score at 6 months (3.4 vs. 5.5; P = .004);
- Depression HADS score at 12 months (3.1 vs. 5.2; P = .004);
- Beck Depression Inventory-II score at 6 months (7.2 vs. 11.5; P = .01); and
- Beck Depression Inventory-II score at 12 months (6.6 vs. 10.9; P = .01).
The median AF burden at 12 months was 0% in the ablation group (interquartile range [IQR], 0-3.22) and 15.5% in the medical therapy group (IQR, 1-45.9), Kalman and colleagues wrote.
“This study highlights the negative impact of AF on patients’ mental health,” Kalman and colleagues wrote. “Compared with medical therapy, catheter ablation resulted in significant and sustained improvements in markers of psychological distress, further focusing attention on the importance of mental health assessment in patients with symptomatic AF. The results of the current study support the role of catheter ablation in relieving symptoms of anxiety and depression in patients with AF.”
Perspective
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There are several key take-home messages from this study. No. 1, this study highlights the effects of atrial fibrillation on not only physical well-being, but mental well-being as well. Notably, in this study of patients with AF, the prevalence of severe psychological distress was a strikingly high 32%.
No. 2, the study suggests that catheter ablation can significantly decrease levels of anxiety and depression that is associated with AF as measured by various questionnaires when compared to medical therapy.
No. 3, the positive effects of catheter ablation in mental well-being are closely tied to the decrease in the burden of AF among patients undergoing the procedure. To date, most clinical trials on catheter ablation of AF have focused on endpoints of death, stroke, heart failure and symptoms. This study sheds new light on the important dimension of understanding the psychological burden associated with AF.
With existing data already present highlighting the superiority of catheter ablation for the treatment of AF for many patients with respect to quality of life and prevention of heart failure, this study further builds on this evidence base. Given the links between AF and triggers associated with stress and anxiety, catheter ablation may be more effective than medical therapy for breaking the loop of AF leading to anxiety, which in turn can trigger more AF.
Given that this was a relatively small study of 100 patients, a larger study is needed to confirm these findings. Given that an invasive procedure can lead to a placebo effect that increases a patient’s sense of well-being due to the expectation of a positive outcome, more studies are needed before these study results may be considered definitive. I am sure that this study will inspire more interest in cardiac psychology and will encourage others who perform clinical trials studying AF treatments to add metrics on psychological distress as endpoints.
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