Afib and PTSD: Preventing the anxiety cycle after a cardiac arrhythmia

Atrial fibrillation a.k.a Afib, can be one of the most traumatizing experience and when these cardiac arrhythmia’s occur, they can leave lasting symptoms of panic or anxiety. I have seen several patient’s this year alone who had an unexpected episode of afib, which is a condition where part of the heart called the atrium, begins to beat erratically, extremely fast and very inefficiently to the point it is a medical emergency. Most people can feel their heart racing and a severe discomfort in their chest. I have seen people from age 18 to age 75 this year alone who had unexpected episodes of afib and they are all left with a rather vicious cycle of fear, anxiety and a realistic chance they could have a repeat episode.

A big part of the complexity comes from the fact even during typical anxiety or panic, one can feel their heart is beating excessively fast, uncomfortably and in an erratic manner. Sometimes these things actually are happening and sometimes it is simply the perception of the person in the midst of an anxiety attack. Normally treatment revolves around reassurance and helping them not be fearful when they have these feelings since usually it is completely benign. The problem with Afib is there is an ongoing legitimate risk of recurrence and one cannot ignore chest discomfort or suspect signs of a repeat episode.

This leads to classic anticipatory anxiety and strengthening of the fear circuitry of the brain. The increase in fear can lead to symptoms of PTSD with a level of hyper-arousal, insomnia, panic attacks and decrease in the ability to function due to the fear. When the episodes of afib continue to are not aggressively treated, the cycle can be exacerbated.
Another complication is untreated anxiety or panic can drive the likelihood of a repeat Afib attack since anxiety and panic heighten the bodies adrenergic tone (adrenaline in the body) which is a separate risk factor for the induction of an episode of Afib. Insomnia is also a risk for driving Afib and since insomnia so often couples anxiety, it can become complicated very quickly.

It is crucial to work with a psychiatrist who is familiar with Afib and the psychological implications. I always aggressively treat the anxiety with typically an SSRI and a benzodiazepine. Over time the benzodiazepine is weaned down and the SSRI remains if necessary. An additional complication is SSRI’s themselves can elongate the QT interval in the heart and can itself induce Afib so careful monitoring is required to control this. It is important the psychiatrist can work closely with the cardiologist to ensure both the afib and psychiatric symptoms are understood and being treated aggressively enough. While sometimes waiting sounds preferential or less aggressive options are suggested by cardiologists, it is often advantageous to be aggressive with treatment as once the fear cycle gets engrained, it becomes more difficult to break.

Additionally, the integration of cognitive behavioral therapy with psychiatric medication and cardiac medication, will maximize the treatment and ensure the best chance for the patient that episodes of Afib do not recur, anxiety and panic don’t consume their lives and overall that they remain enjoying the maximum quality of life as they did before the initial insult of Afib.