Online cognitive behavioral therapy (CBT) improved atrial fibrillation (AF)-specific quality of life (QoL) and reduced health care use in patients with symptomatic paroxysmal AF, a new study shows. These data were reported by Josefin Särnholm, PhD, of the Karolinska Institutet, Stockholm, and colleagues from Sweden and Denmark, in an article published Monday online in the Journal of the American College of Cardiology. AF is present in 2% to 4% of the adult population and is the most common cardiac arrhythmia. Reduction of symptoms—such as palpitations, dizziness, fatigue and dyspnea—and improved QoL are goals in the management of AF. Psychological distress and symptom preoccupation have been shown to exacerbate development of AF disability. In somatic conditions where symptom preoccupation can worsen symptoms of a disease, psychological therapies—such as CBT—can be beneficial in breaking down the mental processes that lead to physical disability. Current interventions for AF exclude treatment of these fear-based behaviors. This single-center randomized controlled trial investigated the QoL outcomes of the use of an internet-delivered CBT protocol for AF-specific cardiac disease. Patients (n=127, mean age=65.4±8.3, 58% female) were evaluated between Jan. 1, 2018, and March 28, 2019, and were assigned to receive AF-CBT (n=65) or standardized AF-education (n=62). A pilot study was performed prior to carrying out the present study. The AF-CBT protocol lasted 10 weeks and was guided by a therapist; exposure to cardiac-related symptoms and reducing AF-related avoidance behaviors were therapeutic targets of the AF-CBT. Investigators conducted baseline, posttreatment and 3-month follow-up visits, and the primary outcome was AF-specific QoL. AF-specific QoL was assessed by the Atrial Fibrillation Effect on QoL summary score (range=0-100) at the 3-month follow-up visit. Patients in the AF-CBT group were followed for 12 months. The secondary outcomes included AF-specific consumption of health care and AF burden—continuous 5-day electrocardiogram (ECG) recordings evaluated burden of AF. AF-specific QoL was significantly improved in the AF-CBT group (QoL summary score was improved by 15 points; 95% confidence interval [CI]=10.1-19.8; p<0.001). Health care consumption was reduced by 56% in the AF-CBT group as well (95% CI: 22% to 90%, p=0.025). However, overall burden of AF did not change. Self-assessment outcomes were continued through 12 months post-treatment. Limitations of the study included the use of standardized AF education as a control group because this did not account for attention from the patients’ caregiver(s). The investigators also noted 5-day ECG patching may not be enough time to reliably measure burden of AF. However, use of an implantable loop recorder to get a longer recording would have been an invasive procedure for a secondary endpoint evaluation. Overall, patients who received internet-delivered AF-CBT—exposure to fears related to cardiac events, avoidance and attempts to control behaviors—showed significant improvements in AF-specific QoL, AF-specific health-care usage, self-reported symptoms of AF and preoccupation of symptoms. The investigators concluded that AF-CBT is both a reasonable treatment method and clinically helpful for patients with AF who experienced limited effectiveness in other treatment methods. In an accompanying editorial, Pamela J. McCabe, PhD, APRN-CNS, of the Mayo Clinic College of Medicine and Science, Rochester, Minnesota, discussed past and current treatment options for patients with AF, and the effectiveness of the treatments we have now. “Along with stroke prevention, lifestyle modifications, and treatment of comorbidity, symptom management is an essential component of AF treatment,” she wrote. She also noted previous studies did not have diversity in interventions nor instruments and had mixed outcomes for psychological treatment of symptom preoccupation, so current evidence could not guide clinical practice. “Särnholm et al. are to be congratulated for the use of rigorous methods and investigating the impact of their intervention on multiple outcomes. Their results add meaningfully to the knowledge base concerning cognitive behavioral interventions for symptom management,” McCabe wrote. The editorialist noted some limitations of the study that may hinder clinical use until further investigation, including patient representation, lack of multiple comorbidities and costs of the AF-CBT intervention. McCabe concluded, “Given these limitations, Särnholm et al. recommend that additional studies are needed to determine if comparable results can be achieved in other cultures and health care environments.” Sources: Särnholm J, Skúladóttir H, Rück C, et al. Cognitive Behavioral Therapy Improves Quality of Life in Patients With Symptomatic Paroxysmal Atrial Fibrillation. J Am Coll Cardiol. 2023;82:46-56. McCabe PJ. Beyond Drugs and Ablation: New Hope for Symptom Management in Patients With Paroxysmal Atrial Fibrillation? J Am Coll Cardiol. 2023;82:57-59. Image Credit: safriibrahim – stock.adobe.com