Anxiety and depression in patients with atrial fibrillation
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https://orcid.org/0000-0002-8559-9598
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions worldwide, with prevalence rising with age. Alongside the growing incidence of AF and an aging population, there is an increasing recognition of the high prevalence of anxiety and depression among AF patients. These psychological comorbidities significantly affect disease progression, treatment adherence, and overall quality of life, necessitating a comprehensive approach to patient management.
Epidemiological studies indicate that anxiety and depression are more common among AF patients than in the general population. The prevalence of depression in AF patients ranges from 22 % to over 40 %, while anxiety is reported in 13 % to 30 % of cases, with variations depending on demographic and regional factors. Meta-analyses confirm that psychological factors – including anxiety, depression, anger, and work stress – are associated with increased AF risk, emphasizing the need for integrated psychiatric care in AF management.
The pathophysiological mechanisms linking psychological distress and AF are multifactorial. Chronic stress and psychological distress activate the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, leading to increased catecholamine levels, atrial remodeling, and a proarrhythmic substrate. Inflammatory pathways also play a central role, with elevated markers such as CRP and IL-6 observed in both AF and depression, suggesting a shared inflammatory environment that may exacerbate both cardiac and neuropsychiatric symptoms. Oxidative stress, autonomic dysfunction, and endothelial dysfunction further contribute to this complex interplay. Recent advances in neurocardiology highlight the bidirectional «heart-brain axis», where autonomic dysregulation, neuroinflammation, and altered neurotrophic signaling link AF pathophysiology with mood disorders.
Studies have shown that higher anxiety and depression levels are associated with more severe AF symptoms, poorer compliance with medical recommendations, and reduced effectiveness of therapy. While optimal AF treatment, especially catheter ablation, can reduce anxiety and depression, pharmacological interventions targeting these conditions have yielded mixed results regarding their impact on AF burden and prognosis.
In summary, effective care of AF patients with coexistent depression or anxiety hinges on an integrated, patient-centered approach that addresses both arrhythmia control and psychological well-being. Further randomized trials are warranted to delineate the long-term impact of combined cardiologic and psychiatric interventions on AF recurrence, stroke risk, and mortality.
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Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 202421 Sep;45(36):3415-3537. https://doi.org/10.1093/eurheartj/ehae177
Wändell P, Carlsson AC, Gasevic D, Wahlström L, Sundquist J, Sundquist K. Depression or anxiety and all-cause mortality in adults with atrial fibrillation – A cohort study in Swedish primary care. Ann Med. 2016;48(1-2):59-66. https://doi.org/10.3109/07853890.2015.1132842
Patel D, Mc Conkey ND, Sohaney R, Mc Neil A, Jedrzejczyk A, Armaganijan L. A Systematic Review of Depression and Anxiety in Patients with Atrial Fibrillation: The Mind-Heart Link. Cardiovasc Neurol. 2013:1-11. https://doi.org/10.1155/2013/159850
Ai Y, Xing Y, Yan L, Ma D, Gao A, Xu Q, Zhang S, Mao T, Pan Q, Ma X, Zhang J. Atrial Fibrillation and Depression: A Bibliometric Analysis From 2001 to 2021. Front Cardiovasc Med. 2022;9. https://doi.org/10.3389/fcvm.2022.775329
Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 21 Sep;45(36):3314–3414. https://doi.org/10.1093/eurheartj/ehae176
Infante-Ventura D, Rodríguez-Díaz B, Bello MÁG, et al. Analysis of therapeutic adherence to antidepressants and associated factors in patients with depressive disorder: A population-based cohort study. J Affect Disord. 2025;385(15). https://doi.org/10.1016/j.jad.2025.119443
Teppo K, Jaakkola J, Airaksinen KE, Biancari F, Halminen O, Putaala J, Mustonen P, Haukka J, Hartikainen J, Luojus A, Niemi M, Linna M, Lehto M. Mental health conditions and adherence to direct oral anticoagulants in patients with incident atrial fibrillation: A nationwide cohort study. Gen Hosp Psychiatry. 2022;74:88-93. https://doi.org/10.1016/j.genhosppsych.2021.12.012
Pino MD, Rivero P, Taylor A, Gabriel R. Impact of Depression and Cardiovascular Risk Factors on Cognitive Impairment in patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis. Arch Gerontol Geriatr. 2024:105601. https://doi.org/10.1016/j.archger.2024.105601
Al-Kaisey AM, Parameswaran R, Bryant C, Anderson RD, Hawson J, Chieng D, Segan L, Voskoboinik A, Sugumar H, Wong GR, Finch S, Joseph SA, McLellan A, Ling LH, Morton J, Sparks P, Sanders P, Lee G, Kistler PM, Kalman JM. Atrial Fibrillation Catheter Ablation vs Medical Therapy and Psychological Distress. JAMA. 2023;330(10):925. https://doi.org/10.1001/jama.2023.14685
Zhuo C, Ji F, Lin X, Jiang D, Wang L, Tian H, Xu Y, Liu S, Chen C. Depression and recurrence of atrial fibrillation after catheter ablation: a meta-analysis of cohort studies. J Affect Disord. 2020;271:27-32. https://doi.org/10.1016/j.jad.2020.03.118
Zhang S, Zhang N, Liu L, Zheng W, Ma ZL, Qiao SY, Zhao YL, Wei YH, Wu G, Yu QT, Deng B, Shen L. Global epidemiology of mental disorder in atrial fibrillation between 1998-2021: A systematic review and meta-analysis. World J Psychiatry. 2024;14(1):179-93. https://doi.org/10.5498/wjp.v14.i1.179
Koleck TA, Mitha SA, Biviano A, Caceres BA, Corwin EJ, Goldenthal I, Creber RM, Turchioe MR, Hickey KT, Bakken S. Exploring Depressive Symptoms and Anxiety Among Patients With Atrial Fibrillation and/or Flutter at the Time of Cardioversion or Ablation. J Cardiovasc Nurs. 2020; Publish Ahead of Print. https://doi.org/10.1097/jcn.0000000000000723
Bae NY, Lee SR, Choi EK, Ahn HJ, Ahn HJ, Kwon S, Han KD, Lee KN, Oh S, Lip GY. Impact of mental disorders on the risk of atrial fibrillation in patients with diabetes mellitus: a nationwide population-based study. Cardiovasc Diabetol. 2022;21(1). https://doi.org/10.1186/s12933-022-01682-7
Zeng J, Qiu Y, Yang C, Fan X, Zhou X, Zhang C, Zhu S, Long Y, Wei Y, Hashimoto K, Chang L. Cardiovascular diseases and depression: A meta-analysis and Mendelian randomization analysis. Mol Psychiatry. 2025. https://doi.org/10.1038/s41380-025-03003-2
Rhee TM, Choi J, Choi EK, Lee KY, Ahn HJ, Kwon S, Lee SR, Oh S, Lip GY. Neuroticism and the Risk of Atrial Fibrillation. JACC. 2023. https://doi.org/10.1016/j.jacasi.2023.09.010
Manolis TA, Manolis AA, Apostolopoulos EJ, Melita H, Manolis AS. Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link. Int J Clin Pract. 2023:1-19. https://doi.org/10.1080/13651501.2023.2248214
Rafaqat S, Afzal S, Khurshid H, Safdar S, Rafaqat S, Rafaqat S. The Role of Major Inflammatory Biomarkers in the Pathogenesis of Atrial Fibrillation. J Innov Card Rhythm Manag. 2022;13(12):5265-77. https://doi.org/10.19102/icrm.2022.13125
Bergstedt J, Pasman JA, Ma Z, Harder A, Yao S, Parker N, Treur JL, Smit DJ, Frei O, Shadrin AA, Meijsen JJ, Shen Q, Hägg S, Tornvall P, Buil A, Werge T, Hjerling-Leffler J, Als TD, Børglum AD, Lewis CM, McIntosh AM, Valdimarsdóttir UA, Andreassen OA, Sullivan PF, Lu Y, Fang F. Distinct biological signature and modifiable risk factors underlie the comorbidity between major depressive disorder and cardiovascular disease. Nat Cardiovasc Res. 2024;3(6):754-69. https://doi.org/10.1038/s44161-024-00488-y
Ramos-Mondragón R, Lozhkin A, Vendrov AE, Runge MS, Isom LL, Madamanchi NR. NADPH Oxidases and Oxidative Stress in the Pathogenesis of Atrial Fibrillation. Antioxidants. 2023;12(10):1833. https://doi.org/10.3390/antiox12101833
Huang J, Wu B, Qin P, Cheng Y, Zhang Z, Chen Y. Research on atrial fibrillation mechanisms and prediction of therapeutic prospects: focus on the autonomic nervous system upstream pathways. Front Cardiovasc Med. 2023;10. https://doi.org/10.3389/fcvm.2023.1270452
Hanna P, Buch E, Stavrakis S, Meyer C, Tompkins JD, Ardell JL, Shivkumar K. Neuroscientific therapies for atrial fibrillation. Cardiovasc Res. 2021;117(7):1732-45. https://doi.org/10.1093/cvr/cvab172
Thompson Ts, Barksdale Dj, Sears Sf, Mounsey Jp, Pursell I, Gehi Ak. The Effect of Anxiety and Depression on Symptoms Attributed to Atrial Fibrillation. Pacing Clin Electrophysiol. 2013;37(4):439-46. https://doi.org/10.1111/pace.12292
Oros M.M. The effect of war on people. Psyche and character changes under war conditions. Ukr Med J. 2023;154(2). Ukrainian. https://doi.org/10.32471/umj.1680-3051.154.241952
Garg PK, O’Neal WT, Diez‐Roux AV, Alonso A, Soliman EZ, Heckbert S. Negative Affect and Risk of Atrial Fibrillation: MESA. J Am Heart Assoc. 2019;8(1). https://doi.org/10.1161/jaha.118.010603
Pavlicek V, Wedegärtner SM, Millenaar D et al. Heart-Focused Anxiety, General Anxiety, Depression and Health-Related Quality of Life in Patients with Atrial Fibrillation Undergoing Pulmonary Vein Isolation. J Clin Med. 2022;11(7):1751; https://doi.org/10.3390/jcm11071751
Zeren M, Karci M, Demir R, Gurses HN, Oktay V, Uzunhasan I, Yigit Z. Cut-off values of 6-min walk test and sit-to-stand test for determining symptom burden in atrial fibrillation. Ir J Med Sci (1971). 2022. https://doi.org/10.1007/s11845-021-02901-y
Vinter N, Calvert P, Kronborg MB, Cosedis-Nielsen J, Gupta D, Ding WY, Trinquart L, Johnsen SP, Frost L, Lip GY. Social determinants of health and recurrence of atrial fibrillation after catheter ablation. A Danish nationwide cohort study. Eur Heart J Qual Care Clin Outcomes. 2022. https://doi.org/10.1093/ehjqcco/qcac071
Ski CF, Taylor RS, McGuigan K, Long L, Lambert JD, Richards SH, Thompson DR. Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation: Cochrane systematic review and meta-analysis. Eur J Cardiovasc Nurs. 2024. https://doi.org/10.1093/eurjcn/zvae113
Helmark C, Ahm R, Brandes A, Skovbakke SJ, Nielsen JC, Frostholm L, Taylor RS, Pedersen SS. Development of an online psychological intervention to prevent depression in patients with atrial fibrillation: lessons learned in a user-centered design study. Feasibility Stud. 2025;11(1). https://doi.org/10.1186/s40814-024-01586-1
de Abajo FJ, García-Rodríguez LA. Risk of Upper Gastrointestinal Tract Bleeding Associated With Selective Serotonin Reuptake Inhibitors and Venlafaxine Therapy. Arch Gen Psychiatry. 2008;65(7):795. https://doi.org/10.1001/archpsyc.65.7.795
Baumgartner C, Fan D, Fang MC, Singer DE, Witt DM, Schmelzer JR, Williams MS, Gurwitz JH, Sung SH, Go AS. Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study. J Am Heart Assoc. 2018;7(8). https://doi.org/10.1161/jaha.117.007814
Sychov OS, Stasyshena OV. Clinical course of atrial fibrillation in patients who experienced coronavirus disease (COVID-19): results of a 6-month follow-up. Medicni Perspekt. 2024;29(3):59-67. https://doi.org/10.26641/2307-0404.2024.3.313515
Jha MK, Qamar A, Vaduganathan M, Charney DS, Murrough JW. Screening and Management of Depression in Patients With Cardiovascular Disease. J Am Coll Cardiol. 2019;73(14):1827-45. https://doi.org/10.1016/j.jacc.2019.01.041
Garg PK, Claxton JN, Soliman EZ, Chen LY, Lewis TT, Mosley T, Alonso A. Associations of anger, vital exhaustion, anti-depressant use, and poor social ties with incident atrial fibrillation: The Atherosclerosis Risk in Communities Study. Eur J Prev Cardiol. 2020:204748731989716. https://doi.org/10.1177/2047487319897163
Lange HW, Herrmann-Lingen C. Depressive symptoms predict recurrence of atrial fibrillation after cardioversion. J Psychosom Res. 2007;63(5):509-13. https://doi.org/10.1016/j.jpsychores.2007.07.010
Koh Y, Kwok C, Voskoboinik A, Kalman JM, Wong M. Serotonin antidepressants and atrial fibrillation burden from cardiac implantable electronic devices. J Arrhythmia. 2023. https://doi.org/10.1002/joa3.12948
Ski CF, Taylor RS, McGuigan K, Long L, Lambert JD, Richards SH, Thompson DR. Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation. Cochrane Database Syst Rev. 2024;2024(4). https://doi.org/10.1002/14651858.cd013508.pub3
Särnholm J, Skúladóttir H, Rück C, Axelsson E, Bonnert M, Bragesjö M, Venkateshvaran A, Ólafsdóttir E, Pedersen SS, Ljótsson B, Braunschweig F. Cognitive Behavioral Therapy Improves Quality of Life in Patients With Symptomatic Paroxysmal Atrial Fibrillation. J Am Coll Cardiol. 2023;82(1):46-56. https://doi.org/10.1016/j.jacc.2023.04.044
Li PW, Yu DS, Yan BP. Nurse-Led Multicomponent Behavioral Activation Intervention for Patients With Atrial Fibrillation: A Randomized Controlled Trial. Circulation. 2024. https://doi.org/10.1161/circep.124.013236
Seredyuk LV, Vakalіuk IP. Clinical-psychological characteristics in patients with a permanent from of atrial fibrillation. Art Med. 2020:149-54. Ukrainian. https://doi.org/10.21802/artm.2020.3.15.149
Wilson RE, Burton L, Marini N, Loewen P, Janke R, Aujla N, Davis D, Rush KL. Assessing the impact of atrial fibrillation self-care interventions: A systematic review. Am Heart J Plus. 2024:100404. https://doi.org/10.1016/j.ahjo.2024.100404
Ladwig KH, Goette A, Atasoy S, Johar H. Psychological aspects of atrial fibrillation: A systematic narrative review. Curr Cardiol Rep. 2020;22(11). https://doi.org/10.1007/s11886-020-01396-w