Psychopathology and Symptoms of Atrial Fibrillation
Psychopathology and Symptoms of Atrial Fibrillation
In this study of 300 stable outpatients with documented AF, we found that psychological comorbidities including depression, anxiety, and somatization are associated with worsened general health status and AF attributed symptom severity. This association persisted regardless of which AF-specific symptoms severity scale was used. In addition, depression specifically was associated with more frequent visits to seek medical attention of AF. There remained an association of psychological distress with patient-perceived AFSS even after adjusting for important confounders including age, gender, working status, education, and comorbidities. Our study demonstrates the important influence of psychological comorbidities on the quality of life of patients with AF, potentially impacting response to therapy. As the prevalence of AF continues to rise to epidemic proportions, psychological comorbidities, which are also quite prevalent, may heavily influence healthcare consumption.
Previous studies have demonstrated the association of psychological comorbidities such as depression or anxiety with worsened outcomes in coronary heart disease and congestive heart failure. However, there are limited data on the association of psychological comorbidities on the natural history and outcomes of patients with AF. Earlier studies have shown that patients with a history of AF and depression have a worsened quality of life than those without depression. These studies have been of limited size, do not control for important confounders, and do not use disease-specific measures of AFSS. A general quality of life scale may not reflect symptoms particular to AF, which often drive treatment considerations. There are even more limited data considering the influence of anxiety on quality of life in AF. Only 2 earlier studies have assessed a disease-specific measure of AFSS. In these studies, AFSS was shown to be influenced by anxiety and depression as measured using the HADS questionnaire. However, these studies had important limitations compared with this study. The earlier studies were much smaller (<100 patients), did not adjust for important confounders (gender, education, medical comorbidities), and had no objective measure of AF burden. The possibility of increased AF burden leading to both increased anxiety and worsened AFSS needs to be addressed, as it was in our study. In addition, no earlier study has considered the influence of somatization on AFSS. No earlier study has considered the novel, well-validated AFEQT and CCS-SAF disease-specific symptom severity scales. And no earlier study has considered the effects of psychological comorbidities on the frequency of visits to seek medical attention of AF.
Although AFSS is greater in patients with various forms of psychological distress, the direction of the relationship is unclear. In a study of over 3,000 patients, increased anxiety was predictive of incident AF in addition to coronary heart disease and mortality. Other studies have shown that depression or anxiety may be associated with incident AF after cardiac surgery or after direct current cardioversion. Potential mechanisms include the heightened inflammatory or autonomic response of psychological distress. However, it is also plausible that AF leads to the development of psychological distress particularly among patients with inadequate knowledge of their condition and ineffective coping strategies. It has been reported that living with the uncertainty and fear of when another episode will occur will increase psychological distress in patients with other supraventricular arrhythmias. Interestingly, we found no relationship between AF burden as measured by a continuous looping monitor and AFSS. This was true even when considering paroxysmal AF patients alone. Regardless, the relationship between psychological distress and symptom burden likely work together to drive patient presentation to clinic.
There are several potential limitations to this study. First, our study is cross-sectional in design and thus causality cannot be determined. However, longitudinal studies from the SMART study will focus on the response of measures of psychological distress to rhythm controlling strategies and the effect of psychological distress on symptomatic benefit with rhythm control. Second, only 2/3 of the participants in our study completed a 1-week continuous monitor. However, in this subset of patients, measures of psychological distress remained associated with higher AFSS scores even after adjusting for AF burden. This suggests that psychological distress is not simply a marker of disease burden. Third, our study was predominately a Caucasian male population so the results may not generalize to women or to other patient populations. However, our findings persisted after adjusting for gender and ethnicity.
Discussion
In this study of 300 stable outpatients with documented AF, we found that psychological comorbidities including depression, anxiety, and somatization are associated with worsened general health status and AF attributed symptom severity. This association persisted regardless of which AF-specific symptoms severity scale was used. In addition, depression specifically was associated with more frequent visits to seek medical attention of AF. There remained an association of psychological distress with patient-perceived AFSS even after adjusting for important confounders including age, gender, working status, education, and comorbidities. Our study demonstrates the important influence of psychological comorbidities on the quality of life of patients with AF, potentially impacting response to therapy. As the prevalence of AF continues to rise to epidemic proportions, psychological comorbidities, which are also quite prevalent, may heavily influence healthcare consumption.
Previous studies have demonstrated the association of psychological comorbidities such as depression or anxiety with worsened outcomes in coronary heart disease and congestive heart failure. However, there are limited data on the association of psychological comorbidities on the natural history and outcomes of patients with AF. Earlier studies have shown that patients with a history of AF and depression have a worsened quality of life than those without depression. These studies have been of limited size, do not control for important confounders, and do not use disease-specific measures of AFSS. A general quality of life scale may not reflect symptoms particular to AF, which often drive treatment considerations. There are even more limited data considering the influence of anxiety on quality of life in AF. Only 2 earlier studies have assessed a disease-specific measure of AFSS. In these studies, AFSS was shown to be influenced by anxiety and depression as measured using the HADS questionnaire. However, these studies had important limitations compared with this study. The earlier studies were much smaller (<100 patients), did not adjust for important confounders (gender, education, medical comorbidities), and had no objective measure of AF burden. The possibility of increased AF burden leading to both increased anxiety and worsened AFSS needs to be addressed, as it was in our study. In addition, no earlier study has considered the influence of somatization on AFSS. No earlier study has considered the novel, well-validated AFEQT and CCS-SAF disease-specific symptom severity scales. And no earlier study has considered the effects of psychological comorbidities on the frequency of visits to seek medical attention of AF.
Although AFSS is greater in patients with various forms of psychological distress, the direction of the relationship is unclear. In a study of over 3,000 patients, increased anxiety was predictive of incident AF in addition to coronary heart disease and mortality. Other studies have shown that depression or anxiety may be associated with incident AF after cardiac surgery or after direct current cardioversion. Potential mechanisms include the heightened inflammatory or autonomic response of psychological distress. However, it is also plausible that AF leads to the development of psychological distress particularly among patients with inadequate knowledge of their condition and ineffective coping strategies. It has been reported that living with the uncertainty and fear of when another episode will occur will increase psychological distress in patients with other supraventricular arrhythmias. Interestingly, we found no relationship between AF burden as measured by a continuous looping monitor and AFSS. This was true even when considering paroxysmal AF patients alone. Regardless, the relationship between psychological distress and symptom burden likely work together to drive patient presentation to clinic.
There are several potential limitations to this study. First, our study is cross-sectional in design and thus causality cannot be determined. However, longitudinal studies from the SMART study will focus on the response of measures of psychological distress to rhythm controlling strategies and the effect of psychological distress on symptomatic benefit with rhythm control. Second, only 2/3 of the participants in our study completed a 1-week continuous monitor. However, in this subset of patients, measures of psychological distress remained associated with higher AFSS scores even after adjusting for AF burden. This suggests that psychological distress is not simply a marker of disease burden. Third, our study was predominately a Caucasian male population so the results may not generalize to women or to other patient populations. However, our findings persisted after adjusting for gender and ethnicity.
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