Anxiety From AF Symptoms Calmed by Cognitive Training

Cognitive-behavioral therapy (CBT) may deserve a place alongside ablation and rhythm- and rate-control drugs as a management option for some people with paroxysmal atrial fibrillation (AF), a new study suggests.

A module-based CBT intervention, conducted online in the small randomized trial, appeared to alleviate cardiac-related anxiety and emotional distress for patients with a history of such responses to perceived AF symptoms.

The 10-week training program, which included exposure therapy aimed at reversing symptom-related fear and other stress behaviors, led to improved quality-of-life (QoL) scores and cut use of healthcare resources compared to a standard AF patient-education program.

The study highlights the contribution of symptom preoccupation, including anxiety avoidance behaviors for perceived AF triggers, to overall disability from paroxysmal AF, say researchers. It points to AF symptom preoccupation as “an important target for treatment” and supports internet-based CBT as a “feasible and clinically effective” intervention, they state in their report, which was published June 26 in the Journal of the American College of Cardiology.

Available treatments for symptomatic paroxysmal AF seldom alleviate all symptoms, lead author Josefin Särnholm, PhD, Karolinska Institutet, Stockholm, Sweden, observed for theheart.org | Medscape Cardiology. “A lot of my patients expect to be symptom free after an ablation.” If that doesn’t happen, she noted, they may become anxious in response to or in anticipation of perceived AF symptoms.

“We know that anxiety and hyper-vigilance when constantly waiting for the next AF episode to strike will increase the perception of symptom severity,” Särnholm said. In such cases, the CBT intervention “could be a very valuable additive treatment.”

Benefit Unrelated to AF Burden

The study randomly assigned 127 patients with paroxysmal AF, all with “AF symptoms experienced as troubling or causing limitations in daily activities,” to follow the online CBT program or to receive standard AF patient education, 65 and 62 patients, respectively. All were on optimal medical therapy and scheduled for catheter ablation or had recently undergone the procedure.

Those who followed the 10-week CBT program showed a 15-point advantage over the standard-care group in summary scores on the Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire (P < .001) at 3 months, a benefit that persisted at the 12-month follow-up. They also showed a 56% drop in cardiac-related healthcare visits compared to the control group (P = .027).

Yet the groups didn’t differ significantly in AF burden, as measured by 5-day continuous ECG monitoring conducted at baseline and at 3 months. Nor did they differ through the study in use of medications, especially antidepressants, anxiolytics, beta blockers, and other drugs with potential influence on stress responses or CBT effectiveness, Särnholm said.

The results of the randomized trial, the “first-known” of its kind, “hold promise for treating patients who experience AF symptom preoccupation,” writes Pamela J. McCabe, PhD, APRN-CNS, Mayo Clinic, Rochester, Minnesota, in an accompanying editorial.

“The improvements in QoL and reductions in cardiac anxiety, depression, disability, and symptoms,” she states, suggest that the trial’s CBT with exposure therapy “may be another tool for symptom management” in such patients.”

It’s noteworthy that QoL improved with CBT despite a lack of differences in AF burden between the two groups, the editorial continues. “This finding should increase our appreciation for the idea that improved QoL and reduced symptom distress are not dependent on reducing objective AF burden.”

The current study “is impressive and important,” Samuel F. Sears, Jr, PhD, told theheart.org | Medscape Cardiology. He emphatically agreed that such CBT training with exposure therapy deserves to be explored as a routine adjunct to catheter ablation for patients with symptomatic AF.

Sears, who specializes in cardiac psychology at East Carolina University, Greenville, North Carolina, isn’t connected with the current report but has played leadership roles in studies of anxiety and QoL related to implantable defibrillator shocks.

The secondary finding of fewer AF-related health visits with CBT, he said, seems encouraging for the strategy’s chances in the United States. But “it would have to be cost-saving or at least cost-neutral for hospital administrators and others to want to invest in this kind of care,” Sears noted. “We would have to prove or show that the benefits would save money.”

Moreover, few clinical groups in the United States have the expertise to conduct such an intervention for patients with AF, he said. That means “we’re not training enough interdisciplinary psychologists and cardiologists.”

Six Modules and Homework

The CBT intervention “emphasizes systematic and repeated exposure to cardiac-related symptoms and avoided situations as well as reducing excessive symptom-controlling behaviors, such as repeated pulse checking,” the report states.

It features six instructional and interactive modules in which the patients engaged online with virtual guidance from a team of specially trained psychologists, who would answer questions and review “homework” assignments by email. The patients would receive “individualized feedback” two to three times per week, Särnholm said. “We made sure that it was highly relevant to each and every individual.”

Even so, the online therapists spent, on average, only about 6 minutes per week on each patient. “It’s a rather cheap additive treatment that we’re trying to implement in routine care in Sweden.”

Särnholm has no disclosures; potential conflicts for the other authors are in the report. McCabe reports no relevant relationships. Sears has disclosed consulting for Medtronic, Abbott, Milestone Pharmaceutical, and Zoll Medical; and receiving honoraria from Medtronic, Biotronik, and Zoll Medical.

J Am Coll Cardiol. Published online June 26, 2023. Abstract, Editorial

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