Beta-blockers may attenuate triggering of atrial fibrillation by anger, stress

By Will Boggs MD

NEW YORK (Reuters Health) - 25/6/2019

Beta-blockers appear to reduce the triggering of atrial fibrillation (AF) by anger or stress, according to results from a prospective study.

"In this study, we found that, for those patients who were treated with beta-blockers, while anger and stress were still associated with an increased likelihood of AF, the association was nowhere near as strong as for those not on beta-blockers," said Dr. Rachel Lampert from Yale University School of Medicine, in New Haven, Connecticut.

"A surprising finding was that experience of anger and stress was not different in those on beta-blockers, who were just as likely to experience the emotion, but rather, the beta-blockers blocked the physiological impact of these negative emotions," she told Reuters Health by email.

Dr. Lampert's team earlier showed that anger and stress are associated with initiation of AF in patients with a history of AF. In the current prospective study of 91 patients with a history of paroxysmal or persistent AF, they investigated whether beta-blockers can protect against emotionally triggered AF.

In the group overall, the odds of having symptomatic AF episodes were 3.94-fold higher with anger and 2.92-fold higher with stress - both significant increases - compared with the odds in their absence.

The likelihood of recurrent AF did not differ between the 56 individuals prescribed beta-blockers and the 37 individuals not prescribed beta-blockers, the researchers report in Heart Rhythm, online June 4.

Moreover, the frequency of anger and/or stress did not differ between those prescribed and those not prescribed beta-blockers.

Anger or stress increased the likelihood of an AF episode in both patients who were prescribed beta-blockers and those who were not. However, the odds of having an AF episode after anger or stress were significantly attenuated in patients prescribed beta-blockers compared with patients not taking the drugs (4.0-fold increased odds vs. 22.5-fold increased odds, P=0.002).

"For many patients, treatment with daily beta-blockers may be beneficial, although our study could not show that, as beta-blocker use was not randomized," Dr. Lampert said. "It did suggest that for some patients, just taking beta-blockers when experiencing anger or stress might be helpful; that's something that further studies should address."

"Talk to your patients about what may be triggering their AF events," she said. "If it's frequently anger or stress, consider beta-blockers. I also talk to my patients about thinking about what mechanisms they have in their lives for reducing stress, which is different for everyone."

Dr. Parveen K. Garg of the Keck School of Medicine of USC, in Los Angeles, who recently examined the relationship between negative affect and the risk of AF, told Reuters Health by email, "The concept that beta-blockers might have a therapeutic effect on treatment of atrial fibrillation beyond simple rate control is highly interesting. Usually we prescribe beta-blockers in the setting of atrial fibrillation to slow conduction from the atria to the ventricles and prevent fast heart rates from occurring. This helps to improve symptoms and reduce cardiac workload. This study suggests that beta-blockers might actually play an additional role in AF management by helping to mitigate the pro-arrhythmic effects associated with negative emotions."

"Prior studies have already documented an association between negative affect, including anxiety, stress, depression, and anger, and increased risk of either primary or recurrent atrial fibrillation," he said. "Physicians should appreciate, however, that this is the first study to suggest that medications are potentially available to reduce this risk."

"Much larger, randomized trials would be required to definitively assess a potential stand-alone beta-blocker indication for reducing pro-arrhythmic effects caused by negative affect," said Dr. Garg, who was not involved in the study. "However, it's possible to imagine a situation, based off these results, to favor prescribing beta-blockers instead of another rate-control agent, like calcium-channel blockers, for a patient with symptomatic AF who is known to be more negative-affect prone."

SOURCE: https://bit.ly/2Wusk3J

Heart Rhythm 2019.

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