Exposure-based cognitive behavior therapy for atrial fibrillation : a novel treatment paradigm

Background: Atrial fibrillation (AF) is a prevalent arrhythmia associated with symptoms such as irregular heartbeat, palpitations, dyspnea, chest pain and fatigue. In many patients, AF symptoms are not alleviated by current treatment strategies and there is a clinical need for better symptom management. AF is associated with low quality of life (QoL) and psychological distress, and patients often present with symptom preoccupation; i.e., fear of AF symptoms and avoidance behavior. Symptom preoccupation may play an important role in AF disability and is associated with higher self-reported symptom severity and low QoL.

Aims: The overall objective of this doctoral project is to develop and evaluate a novel, AF-specific, exposure-based internet-delivered cognitive behavior therapy (AF-CBT) protocol to increase QoL and potentially reduce symptom burden in patients with symptomatic paroxysmal AF. The specific aims consist of the following: investigate the feasibility, acceptability and potential efficacy of a novel treatment protocol of exposure-based AF-CBT delivered face-to-face (Study I) or via the Internet (Study II); investigate the efficacy of internet-delivered exposure-based AF-CBT compared to a waitlist receiving standardized AF education (Study III); investigate if reduction in symptom preoccupation, i.e., cardiac-related fear, hypervigilance and avoidance behavior, mediates the therapeutic effect of AF-CBT (Study IV).

Methods: The feasibility, acceptability and potential efficacy of the AF-CBT protocol were evaluated in two uncontrolled pilot studies (Study I and II). The treatment’s efficacy was further investigated in a randomized controlled trial (RCT), where a total of 127 participants were randomized to 10 weeks of AF-CBT (n=65) or to a waitlist offered standardized AF education (AF-EDU; n=62 (Study III)). All participants were diagnosed with paroxysmal symptomatic AF and were referred by a cardiologist (Study I and II) or self-referred (Study III). The participants underwent thorough cardiac evaluations and psychological assessments to ensure that they received medical treatment according to current guidelines. The treatment was therapist-guided exposure-based AF-CBT delivered face-to-face (Study I) or over the Internet (Study II and III) for 10 weeks. The treatment targeted two proposed maintaining factors of AF disability: fear of AF symptoms and AF-related avoidance behavior. The primary outcome was AF-specific QoL and secondary outcomes included, among others, self-reported AF symptoms, symptom preoccupation, general QoL, depression, stress, healthcare utilization and objective AF burden measured by electrocardiogram (ECG). In order to explore potential mediators of the treatment effect, data from the RCT was used to conduct a mediation analysis, with weekly assessments of three putative mediators (cardiac-related fear, hypervigilance and avoidance behavior) and treatment outcome (AF symptoms and disability (Study IV)).

Results: AF-CBT rendered high adherence, satisfaction and treatment completion (Study IIII). We observed large to medium effect sizes, with stable effects six-months after the treatment (Study I and II). In Study III, AF-CBT led to large and superior between-group improvement in AF-specific QoL (primary outcome) three months after the treatment. Significant improvements were also observed on all relevant outcomes in favor of AF-CBT. The results were sustained 12 months after the treatment. No significant difference in objective AF burden between the groups at three-month follow-up was detected. The analysis of mediators showed that a reduction in symptom preoccupation, i.e., cardiac-related fear, hypervigilance and avoidance behavior mediated the treatment effect of self-reported AF symptoms and disability.

Conclusion: Internet-delivered exposure-based AF-CBT is feasible, acceptable and clinically effective for patients with AF. The results support a treatment strategy targeting symptom preoccupation via exposure-based CBT to reduce AF symptoms and disability. AF-CBT administered via the Internet has the capacity to ameliorate the well-being of a large group of patients that do not achieve satisfactory improvement from current treatment methods.

List of scientific papers

I. Särnholm J*, Skúladóttir H*, Rück C, Pedersen SS, Braunschweig F, Ljótsson B. Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: An Uncontrolled Pilot Study. Behavior Therapy. 2017;1–14. *Equal contributors.
https://doi.org/10.1016/j.beth.2017.06.001

II. Särnholm J, Skúladóttir H, Rück C, Klavebäck S, Ólafsdóttir E, Pedersen SS, Braunschweig F, Ljótsson B. Internet-Delivered Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: Uncontrolled Pilot Trial. JMIR Cardio. 2021;5(1):e24524.
https://doi.org/10.2196/24524

III. Särnholm J, Skúladóttir H, Rück C, Axelsson E, Bonnert M, Bragesjö M, Venkateshvaran A, Ólafsdóttir E, Pedersen SS, Ljótsson* B, Braunschweig* F. Internet-delivered Cognitive Behavioral Therapy for Symptom Preoccupation in Atrial Fibrillation: A Randomized Controlled Trial. *Equal contributors. [Manuscript]

IV. Särnholm J, Axelsson E, Skúladóttir H, Bonnert M, Bragesjö M, Rück C, Pedersen SS, Braunschweig F, Ljótsson B. The role of Cardiac-related Fear, Hypervigilance and Avoidance Behavior in Exposure Therapy for Atrial Fibrillation: A Mediation Analysis. [Manuscript]