The use of antidepressants and the risk of chronic atrial fibrillation

Serotonin antidepressants and atrial fibrillation burden from cardiac implantable electronic devices

Objective

Depression and anxiety show a bidirectional relationship with atrial fibrillation (AF). Antidepressant use is associated with a reduction in the incidence of AF. However, no studies have examined the relationship between antidepressant use and AF burden (time in AF). This retrospective cohort study examined cardiac implantable device-detected AF episodes and their relationship with antidepressant use, among other treatment factors.

Methods

Consecutive patients from the Western Health Cardiology Department attending pacemaker checks between 2015 and 2021 were included. Patients with permanent AF were excluded, yielding 285 patients with no or paroxysmal AF, with a total of 772 patient encounters. Generalized estimating equations were used to model two processes: binary AF (present/absent) and the number of days in AF for patients with AF.

Results

Each yearly increase with age was associated with an increase in the odds of developing AF (OR 1.03 [1.00-1.05], p = .027). Male gender conferred a reduction in AF incidence (OR 0.30 [0.13-0.68], p = .004). Digoxin use was associated with incident AF (OR 4.43 [1.07-18.4], p = .04). Sotalol and heart-failure beta blocker use were associated with a decrease in AF burden (IRR 0.30 [0.12-0.78], p = .013 and 0.33 [0.14-0.81], p = .015). Selective serotonin reuptake inhibitor antidepressant use was associated with reduced AF burden (IRR 0.27 [0.09-0.81], p = .019), as was selective serotonin/noradrenaline reuptake inhibitor use (IRR 0.07 [0.03-0.15], p < .001).

Conclusions

Older age, female gender and digoxin are associated with a higher odds of developing incident AF. Sotalol, heart failure beta blockers and serotonin-based antidepressants are associated with reduced AF burden. Further prospective study into the effects of antidepressants on atrial arrhythmias is warranted.

Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link

OBJECTIVE

To explore the reciprocal relationship of depression and atrial fibrillation (AF).

METHODS

A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies.

RESULTS

There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation.

CONCLUSIONS

A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.

Association of Depression, Antidepressants With Atrial Fibrillation Risk: A Systemic Review and Meta-Analysis

Background

Depression is a possible influence factor for the increased risk of incident atrial fibrillation (AF). Although several investigations have assessed their association, the results are still controversial. Therefore, we conducted a meta-analysis to evaluate the association between depression or using antidepressants and AF.

Methods

We systemically performed the literature retrieval from two electronic databases PubMed and EMBASE until March 2022 to extract relevant data. The hazard ratios (HRs) and odds ratios (OR) from included studies with 95% confidence intervals (CIs) were adjusted into the risk ratio (RR) and pooled by using the random-effects model.

Results

Totally 9 studies about the associations between depression or antidepressants and incident AF risk were included in this meta-analysis. Among them, 5 studies specifically analyzed the impact of antidepressants on the risk of AF. The outcomes of our analysis indicated that depression or depressive symptoms could increase AF risk (RR = 1.15, 95% CI, 1.03–1.27, P < 0.01). In addition, the use of antidepressants can also increase AF risk (RR = 1.16, 95% CI, 1.07–1.25, P < 0.001). These results remained unchanged when we remove the source of heterogeneity or adjust the analysis model into the fixed-effects model.

Conclusions

Based on existing investigations, both depression and the use of antidepressants are closely related to the increase of incident AF risk.

Associations of Antidepressants With Atrial Fibrillation and Ventricular Arrhythmias: A Systematic Review and Meta-Analysis

Background

Several published studies have disagreements on whether the use of antidepressants is associated with increased risk of arrhythmias. In this study, we performed this meta-analysis to assess the association of antidepressants with cardiac arrhythmias in patients who require antidepressants.

Methods

The PubMed and Embase databases were systematically searched until December 2021 to find studies that investigated the association between antidepressant use and cardiac arrhythmias. Studies that assessed the effects of any antidepressant on arrhythmias in patients who require antidepressants compared with those who require no antidepressants were included. We used a random-effects model to pool the adjusted risk ratios (RRs) and 95% confidence intervals (CIs). The stability of the results was examined by omitting an individual study at a time.

Results

A total of 3,396 studies were screened and 6 studies with 2,626,746 participants were finally included in this meta-analysis. When compared with no antidepressants, the use of antidepressants was significantly associated with an increased risk of atrial fibrillation (RR = 1.37, 95% CI: 1.16–1.61). However, there was no difference in the risk of ventricular arrhythmias or sudden cardiac death (RR = 1.33, 95% CI: 0.88–2.01) between the two studied groups. In the subgroup analysis, tricyclic antidepressants (RR = 1.12, 95% CI: 0.89–1.41), selective serotonin reuptake inhibitors (RR = 1.46, 95% CI: 0.63–3.38), and selective serotonin reuptake inhibitors (RR = 0.99, 95% CI: 0.97–1.01) did not increase the risk of ventricular arrhythmias and/or sudden cardiac death.

Conclusion

Recently published data suggested that the use of antidepressants did not increase the risk of ventricular arrhythmias or sudden cardiac death. Antidepressants were associated with an increased risk of atrial fibrillation but that still needs further confirmation.

Psychological aspects of atrial fibrillation: A systematic narrative review : Impact on incidence, cognition, prognosis, and symptom perception

PURPOSE OF THE REVIEW

Atrial fibrillation (AF) is the most frequent arrhythmia in the general population. This review aims to provide a comprehensive overview of the psychological aspects of AF, compiling evidence from epidemiological, clinical, and basic research sources.

RECENT FINDINGS

Findings from large-scale population-based and clinical longitudinal studies reveal an association between negative affectivity (e.g. depression) and the incidence and clinical prognosis of AF. Studies investigating the impact of work stress parameters on AF onset show conflicting results. Researchers have reported the impact of AF on cognitive decline and on health-related quality of life, and have highlighted the role of interoceptive cues in the development of AF symptom burden and gender differences in psychological covariates of AF. Among biological pathways linking psychosocial factors to AF, research on autonomic regulation has yielded the most evidence so far, showing that the onset of AF is associated with simultaneous sympatho-vagal activation rather than an increase in vagal or sympathetic drive alone. Thus, modulation of the autonomic nervous system is likely to be a promising strategy for protecting the myocardium from pro-arrhythmic autonomic influences. In total, the findings show that AF is embedded as a disease condition in a psycho-societal context and is not an isolated medical problem per se. A broader perspective than a focus on the electrophysiology alone is urgently needed.

Relationship between psychological factors and atrial fibrillation: A meta-analysis and systematic review

BACKGROUND

Although several studies have investigated the role of psychological factors in atrial fibrillation (AF), the results are still under debate. Therefore, we performed a meta-analysis to examine the relationship between psychological factors and the risk of incident AF.

METHODS

We systematically searched the PubMed and EMBASE databases from inception to December 2019 to identify eligible studies. The hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled by using a random-effects model.

RESULTS

A total of 11 cohort studies were included in this meta-analysis. There were 5, 2, 4, and 5 studies examining the association of anxiety, anger, depression, and psychological stress with AF, respectively. In the pooled analysis by a random-effects model, anxiety (HR = 1.10, 95%CI 0.97-1.24; P = .14), anger (HR = 1.08, 95%CI 0.95-1.23; P = .21), depression (HR = 1.15, 95%CI 0.98-1.35; P = .08), and work stress (HR = 1.14, 95%CI 0.98-1.34; P = .09) were not associated with the risk of AF. These results were not changed when we re-performed the analysis using a fixed-effects model.

CONCLUSIONS

Based on current evidence, no associations were observed for anger, anxiety, and work stress with the risk of AF.

Posttraumatic Stress Disorder and Risk for Early Incident Atrial Fibrillation: A Prospective Cohort Study of 1.1 Million Young Adults

Background Acute psychological stress and negative emotions are known risk factors for atrial fibrillation (AF). Whether exposure to chronic stress syndromes, such as posttraumatic stress disorder (PTSD), also increases susceptibility to AF is unknown. Methods and Results We prospectively assessed the incidence of AF over a 13-year period among 988 090 young and middle-aged veterans (mean age, 30.29±9.19 years; 87.8% men, 64.5% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of AF, atrial flutter, or atrial tachycardia at baseline. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of PTSD to new AF. We also tested for effect modification by sex and controlled for healthcare use. During a mean follow-up of 4.8 years, 2491 patients were diagnosed with AF. Patients with PTSD had a higher overall incidence of AF (P<0.0001) and were more likely to develop AF at a younger age than those without PTSD (P=0.004). PTSD was significantly associated with incident AF in unadjusted models (hazard ratio, 1.31; 95% CI, 1.19-1.43) and models that adjusted for demographics, lifestyle factors, cardiovascular risk factors, and depression (hazard ratio, 1.13; 95% CI, 1.02-1.24). The interaction with sex was nonsignificant (P=0.93). Conclusions PTSD was associated increased risk for early incident AF after adjustment for established AF risk factors and depression in this cohort of young and middle-aged veterans. Findings from this study require validation in more diverse populations to determine their generalizability.

Depression, antidepressants, and the risk of non-valvular atrial fibrillation: A nationwide Danish matched cohort study

Background

Depression is associated with an increased risk of a series of cardiovascular diseases and with increased symptom burden in patients with atrial fibrillation. The aim of this study was to determine the association between depression as well as antidepressant treatment and the risk of incident atrial fibrillation.

Design

A nationwide register-based study comparing the atrial fibrillation risk in all Danes initiating antidepressant treatment from 2000 to 2013 ( N = 785,254) with that in a 1:5-matched sample from the general population.

Methods

Cox regression was used to estimate adjusted hazard ratios (aHRs) and associated 95% confidence intervals (95% CIs), both after initiation of treatment and in the month before when patients were assumed to have medically untreated depression.

Results

Antidepressant treatment was associated with a three-fold higher risk of atrial fibrillation during the first month (aHR = 3.18 (95% CI: 2.98–3.39)). This association gradually attenuated over the following year (aHR = 1.37 (95% CI: 1.31–1.44) 2–6 months after antidepressant therapy initiation, and aHR = 1.11 (95% CI: 1.06–1.16) 6–12 months after). However, the associated atrial fibrillation risk was even higher in the month before starting antidepressant treatment (aHR = 7.65 (95% CI: 7.05–8.30) from 30 to 15 days before, and aHR = 4.29 (95% CI: 3.94–4.67) the last 15 days before). Overall, 0.4% of patients were diagnosed with atrial fibrillation from 30 days before to 30 days after antidepressant treatment.

Conclusions

Antidepressant users had a substantially increased atrial fibrillation risk, particularly before treatment initiation. Whether this mirrors a causal relation between depression and atrial fibrillation may have large consequences for public health and should be discussed.