Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

doi:10.1016/j.hrtlng.2009.12.010

Heart & Lung

Volume 40, Issue 1, January–February 2011, Pages 4-11

https://doi.org/10.1016/j.hrtlng.2009.12.010 Get rights and content

Abstract

Objective

We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery.

Methods

Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization.

Results

Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P < .001). No baseline psychological predictors were associated with AF. When postoperative distress measures were considered, anxiety was associated with increased odds of AF (odds ratio, 1.09; 95% confidence interval, 1.00 to 1.18; P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P < .001). Analyses specific to the symptomatic expression of anxiety indicated that somatic (ie, autonomic arousal) and cognitive-affective (ie, subjective experiences of anxious affect) symptoms were associated with incident AF.

Conclusion

Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF.

Section snippets

Patient Sample

The sample for this study consisted of patients undergoing first-time CABG surgery between January 1999 and December 2005. Six hundred and eighty-one patients scheduled for isolated CABG were evaluated in terms of our inclusion criteria: age >18 years, CABG procedure with cardiopulmonary bypass, ability and willingness to provide informed consent, and undergoing elective or urgent surgery. Four hundred and forty-three patients were deemed ineligible. The most common reason was residence outside

Results

Fifty-six patients (24.8% of total) were identified as manifesting postoperative AF, and the descriptive features of the sample and univariable predictors of AF are shown in Table 1. The retained predictors of AF, based on the univariable logistic regression, included older age, mitral incompetence, left-ventricular ejection fraction (LVEF) ≤30%, and urgent procedures. An inspection of preoperative medications indicated that 3 patients in the sample had been prescribed preoperative warfarin,

Discussion

This study showed that postoperative anxiety was associated with increased odds for AF after CABG, and is in general concordance with work in non-CABG populations.7, 33 These findings do not indicate that anxiety is predictive of AF, but rather that anxiety is associated with concurrent AF. A differential pattern was revealed with respect to cognitive-affective and somatic anxiety symptoms.

Postoperative autonomic arousal symptoms were associated with AF. This finding was not surprising, given

Acknowledgments

This research was supported by an Australian Postgraduate Award and the Sir Robert Menzies Memorial Research Scholarship in the Allied Health Sciences to P.J.T.

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Self-affirmations help one focus on positive outcomes and adapt to new situations both psychologically and physiologically by the repetition of positive affirmation sentences. This method, which has promising results in symptom management, is predicted to have effective results in the management of pain and discomfort in patients undergoing open-heart surgery.
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This study adopted a randomized controlled pretest-posttest follow-up research design. The study was conducted at a public training and research hospital (Istanbul, Turkey) specialized in thoracic and cardiovascular surgery. The sample consisted of 61 patients randomized into two groups: intervention (n = 34) and control (n = 27). The participants of the intervention group listened to a self-affirmation audio recording for three days after surgery. Anxiety levels and perceived discomfort regarding pain, dyspnoea, palpitations, fatigue and nausea were measured daily. The State Trait Anxiety Inventory (STAI) was used to measure the level of anxiety, meanwhile perceived discomfort regarding pain, dyspnoea, palpitations, fatigue and nausea were measured by a 0 to 10 Numeric Rating Scale (NRS).
The control group had significantly higher anxiety than the intervention group three days after surgery (P < 0.001). The intervention group had less pain (P < 0.01), dyspnoea (P < 0.01), palpitations (P < 0.01), fatigue (P < 0.001) and nausea (P < 0.01) than the control group.
Positive self-affirmation helped reduce anxiety and perceived discomfort in patients who underwent open-heart surgery.
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Citation Excerpt :
Preoperative anxiety has been shown to strongly predict hospital readmission following CABG, even controlling for relevant medical variables (Tully et al., 2008). Presurgical anxiety is also associated with increased odds of in-hospital complications like stroke and MI (Tully et al., 2011b), post-surgical AF (Tully et al., 2011a), and increased long-term mortality (Tully et al., 2008), with the latter study noting that this effect was unique to anxiety and not observed with preoperative depression. Furthermore, preoperative anxiety is associated with persisting mental health symptoms post-operatively (Krannich et al., 2007; Oxlad and Wade, 2008).
Anxiety is associated with many forms and facets of heart disease, and, by extension, neurologic manifestations of heart disease. Despite its seeming self-evidence, anxiety is challenging to consistently define, measure, and operationalize in the context of medical research. Various diagnostic nosologies have been defined and refined over time, but anxiety is also a universal human experience that may be “normal” in many circumstances, particularly in the face of major medical issues. For these and other reasons, the research on anxiety and heart disease is mixed, incomplete, and often characterized by challenging questions of causality. Nonetheless, a broad body of literature has established clear connections between anxiety and vascular risk factors, cardiac disease, and cardiac surgery. These relationships are often intuitive, with research suggesting, for example, that chronic activation of the sympathetic nervous system is associated with increased risk of heart disease. However, they are sometimes complexly reciprocal or even surprising (e.g., with high-anxiety individuals found to have better outcomes in some cardiac conditions by virtue of seeking evaluation and treatment earlier). This chapter reviews the construct of anxiety and its complexities, its associations with heart disease, and the established treatments for anxiety, concluding with questions about anxiety, heart disease, and their optimal management that still need to be answered.
Perception of atrial fibrillation in dependence of neuroticism
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Atrial fibrillation (AF) is associated with a varying symptom burden, which ranges from completely unawareness to disabling conditions. The present cross-sectional study tried to assess if neuroticism is associated with a greater degree of perception of AF related symptoms.
162 patients who were considered for catheter ablation of AF were included. AF related symptom burden was quantified according to the European Heart Rhythm Association (EHRA) score. Personality traits were assessed using the Big Five personality traits (5BT).
Female patients reported higher symptom burden. Higher EHRA scores were furthermore associated with treatment with antiarrhythmic agents, digitalis, direct oral anticoagulants (DOAC), and antidepressant treatment, as well as suffering from heart failure or chronic kidney disease. Neuroticism showed a positive correlation to AF related symptom burden with significantly higher neuroticism scores in patients with higher EHRA scores (Rho = 0.41; 95%CI 0.26 to 0.53; p < .001), while no association was demonstrated for the other four personality traits. Multiple linear regression analysis revealed neuroticism as strongest independent predictor for symptomatic AF, followed by treatment with antiarrhythmic agents and DOAC.
Perception of AF related symptoms is a multifactorial process, which in our cohort was independently associated with neuroticism. Patients with higher symptom burden were also more likely to receive antiarrhythmic agents and DOAC, as well as antidepressants.
German registry for clinical studies (DRKS), DRKS00019007.
Depression and recurrence of atrial fibrillation after catheter ablation: a meta-analysis of cohort studies
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Citation Excerpt :
These studies, together with our findings, suggest that greater efforts should be made to manage potential affective disorders in patients scheduled for, as well as after, catheter ablation for AF (Risom et al., 2019). A potential association between depression and AF risk has been indicated in studies of AF patients after electrical cardioversion (Lange and Herrmann-Lingen, 2007), patients who received cardiac surgery (Tully et al., 2011), and the general population (Garg et al., 2019; Whang et al., 2012). Potential mechanisms underlying the association between depression and AF remain unclear.
: The influence of depression on the recurrence of atrial fibrillation (AF) after catheter ablation remains unclear. We performed a meta-analysis to evaluate the association between depression and AF recurrence after catheter ablation.
: Cohort studies that evaluated depression at baseline and correlated depression with AF recurrence after catheter ablation were identified by searching the PubMed and Embase databases. Heterogeneity was determined using the Cochrane's Q test and calculating the I² statistic. A random-effect model was applied to incorporate the potential influence of heterogeneity.
: Our analysis included seven cohort studies with 1,070 AF patients who underwent catheter ablation by circumferential pulmonary vein isolation. No significant heterogeneity was detected among the included studies (p for Cochrane's Q test = 0.20, I² = 29%). Pooled results showed that depression before procedure was independently associated with increased risk of AF recurrence after catheter ablation (adjusted relative risk [RR]: 2.24, 95% confidence interval [CI]: 1.75 - 2.88, p < 0.001). Sensitivity analyses, conducted by omitting one study at a time, retrieved similar results (RR: 2.06 - 2.53, p all < 0.05). Predefined subgroup analyses showed that the association between depression and AF recurrence after catheter ablation was consistent regardless of the study characteristics, including study location, study design, patient number, type of AF, follow-up duration, adjustment of left atrial dimension, and quality score.
: This analysis included a limited number of studies and various instruments applied to measure depression.
: Depression is an independent risk factor of AF recurrence after catheter ablation.
Relationship Between Psychosocial Stressors and Atrial Fibrillation in Women >45 Years of Age
2018, American Journal of Cardiology
Negative emotions have been linked to the development of atrial fibrillation (AF), and positive effect may be protective. However, there are few large-scale studies examining the association between psychosocial stressors that may provoke these emotions and the occurrence of AF. We examined the cross-sectional relation between psychosocial stress and AF in 24,809 women participating in the Women's Health Study. Participants answered questions about work stress (e.g., excessive work, conflicting demands), work-family spillover stress (e.g., too stressed after work to participate in activities with family), financial stress (e.g., difficulty paying monthly bills), traumatic life events (e.g., death of a child), everyday discrimination (e.g., less respect, poor service), intimate partner stress (e.g., how judgmental is your spouse/partner), neighborhood stress (e.g., neighborhood safety, trust), negative life events within 5 years (e.g., life threatening illness, legal problems), and cumulative stress (a weighted measure of the stress domains). The prevalence of confirmed AF was 3.84% (N = 953) and risk factor profiles differed by AF status. Women with AF reported significantly higher financial stress, traumatic life events, and neighborhood stress (p_each < 0.05). Only traumatic life events (odds ratio 1.37, 95% confidence interval 1.19 to 1.59) was significantly associated with AF after adjustment for cardiovascular risk factors, socioeconomic and psychosocial status. These large-scale cross-sectional data thus indicate a potential relationship between traumatic life events and AF in older women.
Preoperative mental illness and postoperative atrial fibrillation in cardiac surgery patients: Identifying a vulnerable population
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View all citing articles on Scopus

: Cite this article: Tully, P. J., Bennetts, J. S., Baker, R. A., McGavigan, A. D., Turnbull, D. A., & Winefield, H. R. (2011, JANUARY/FEBRUARY). Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery. Heart & Lung, 40(1), 4-11. doi:10.1016/j.hrtlng.2009.12.010.

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Issues in Cardiovascular NursingAnxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

Abstract

Objective

Methods

Results

Conclusion

Section snippets

Patient Sample

Results

Discussion

Acknowledgments

J Am Coll Cardiol

Ann Thorac Surg

Int J Cardiol

Psychosomatics

Psychosomatics

J Psychosom Res

Behav Res Ther

Behav Res Ther

J Thorac Cardiovasc Surg

J Psychosom Res

Am Heart J

J Psychosom Res

Heart Lung

Patient Educ Couns

Epidemiology, mechanisms and risks: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery

Chest

Pharmacologic prophylaxis: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery

Chest

Atrial arrhythmias after cardiac surgery in patients with diabetes mellitus

Clin Res Cardiol

Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources

Circulation

The influences of psychosocial aspects and anxiety symptoms on quality of life of patients with arrhythmia: investigation in paroxysmal atrial fibrillation

Int J Behav Med

Understanding atrial symptom reports: objective versus subjective predictors

PACE

Depression, the autonomic nervous system, and coronary heart disease

Psychosom Med

Issues in Cardiovascular Nursing
Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery