1. CoRPS Center of Research on Psychology in Somatic diseases Depression and anxiety in atrial fibrillation patients - is this undertreated? Susanne S. Pedersen, Professor of Cardiac Psychology

2. CoRPS Disclosures Moderate speaker or consultancy fee from: Medtronic St. Jude Medical Cameron Health Sanofi Aventis

3. CoRPS Affiliations Prof.dr. Susanne S. Pedersen CoRPS - Center of Research on Psychology in Somatic diseases, Tilburg University, The Netherlands Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Department of Cardiology, Odense University Hospital, Denmark Phone: + 31 (0) 13 466 2503 E-mail: s.s.pedersen@uvt.nl www.tilburguniversity.nl/corps

4. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

5. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

6. CoRPS What is atrial fibrillation Most common type of sustained cardiac arrhythmia, affecting over 2 million patients in the United States Not directly life-threatening, but associated with poor quality of life and increased risk of stroke, heart failure and mortality Pathophysiology: Disorganized electrical activity of the atria AF treatment –rate control –rhythm control e.g. electrical cardioversion, radiofrequency ablation

7. CoRPS Types of atrial fibrillation (i)First detected episode of AF (ii)Paroxysmal AF - self-terminating episodes lasting no longer than seven days, commonly less than 24 hours (iii)Persistent AF - non-self-terminating episodes lasting more than 7 days, requiring electrical or pharmacological cardioversion to terminate (iv)Permanent AF - fails to terminate after cardioversion, or is accepted by the patient and the physician Fuster et al. ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation. Circulation, 2006;114:700–52 Severity

8. CoRPS Risk factors for incident AF Bajpai et al. US Cardiovascular Disease 2007

9. CoRPS What about distress as a risk factor for incident AF? Eaker et al. Psychsom Med 2005;67:692-6 Framingham offspring study ( N = 3682 )

10. CoRPS Lone AF - definition AF in the absence of the above risk factors or underlying heart disease Accounts for 12-30% of all AF Accounts for 20-45% of AF in younger patients

11. CoRPS AF prevalence rates Prevalence based on large population-based cohorts: 0.9% 3-5% in people older than 65 years 10% or higher in people >80 years Feinberg et al. Arch Intern Med 1995;155:469–73 Stewart et al. Heart, 2001;86:516–21 Life-time risk of AF: From age 40 years onwards - one in four for both men and women In the absence of congestive heart failure or myocardial infarction - one in six

12. CoRPS Projected prevalence of AF in 2050 Miyasaki et al. Circulation 2006;114:119-25 Increasing population with AF

13. CoRPS Economic burden of AF Kim et al. Circulation Cardiovasc Qual Outcomes online 3 May 2011 Principal driver of cost difference

14. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

15. CoRPS Distress in AF patients compared to other cardiac populations Redhead et al. J Psychosom Res 2010;69:555-63

16. CoRPS Distress at baseline and at 6 months Thrall et al. Chest 2007;132:1259-64 AF: N = 101 Hypertensive: N = 97 Mean anxiety scores remain stable over a 6-month period

17. CoRPS Stability of distress over time – what about HRQoL scores... Lane et al. J Psychosom Res 2009;203-10 NS ↓ Lone AF: N = 70 Prevalence of distress in AF patients is equivalent to that seen in other cardiac populations and persists once manifest

18. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

19. CoRPS Treatment of anxiety and depression in AF Author (year)N (patients) Study design (mths) Measure% distress% psychotropics Ariansen (2011)27 (AF)CHADS13% depression 17% anxiety 11% Frasure-Smith (2009)974 (AF-CHF)P (24-74)BDI-II32% depression? Lange (2007)54 (AF)P (2)HADS24% depression 32% anxiety 0% Lane (2009)70 (lone AF)P (B, 6, 12)STAI-S STAI-T 39%, 31%, 36% 41%, 27%, 21% ? Ong (2006)93 (AF)CHADS11% depression8% Redhead (2010)50 (AF)CHADS16% depression 26% anxiety 7% 13% Thrall (2007)101 (AF)P (6)BDI STAI-S 38% depression 28% anxiety? 7/17 studies focusing on anxiety/depression and reporting %

20. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

21. CoRPS Depression and AF recurrence Lange et al. J Psychosom Res 2007;63:509-13

22. CoRPS Depression and AF recurrence Lange et al. J Psychosom Res 2007;63:509-13 Multivariate analysis of the risk of AF recurrence including variables found to be predictive in univariate analysis

23. CoRPS Cardiovascular death-free survival stratified by depression symptoms and rhythm- versus rate-control Frasure-Smith et al. Circulation 2009;120:134-40 N=947 comorbid AF-CHF Atrial Fibrillation and Congestive Heart Failure trial Rate-control (i.e., beta- blockers and digoxin) versus rhythm-control (i.e., antiarrhythmic medications and electrical cardioversion) 32% had BDI-II scores 14 (mild to moderate symptoms of depression)

24. CoRPS ICD patients - posttraumatic stress symptoms and mortality Ladwig et al. Arch Gen Psychiatry 2008;65:1325-30 N = 147

25. CoRPS Down in the dumps Feeling blue Angry Worried Bad mood Unhappy Type D ? Type D personality - burden of increased negative emotions and inhibition No!! I do not want to share my emotions with others… No!! I do not want to share my emotions with others…

26. CoRPS ICD patients - anxious Type D patients and ventricular arrhythmias van den Broek, Denollet et al. J Am Coll Cardiol 2009;54:531-7 N = 391

27. CoRPS Pedersen, Theuns, Jordaens et al. Europace 2010;12:1446-52 ICD patients - Type D personality and pre- implantation ICD concerns and mortality N = 371 HR: 3.65; 95%CI: 1.57-8.45; p =.003 18.2% 5.2%

28. CoRPS Why would depression be bad for AF patients? Depression CAD Hemostatic changes Elevated blood pressure Activation of the HPA-axis  HRV Health- related behaviours Release of stress hormones Endothelial damage Inflammation Poor prognosis Risk factor clustering Non- compliance Also effects on QoL, adherance, and compliance !!!

29. CoRPS Overview Epidemiology of atrial fibrillation (AF) Prevalence of distress in AF Is distress treated in AF patients? Consequences of distress in AF patients Research and clinical implications

30. CoRPS Emotional distress in AF 2/3 of patients experience significant symptoms: Tachycardia-related (sympathetic): palpitations, exercise intolerance Congestion-related: shortness of breath, fatigue/lack of energy 2/3 of patients experience significant symptoms: Tachycardia-related (sympathetic): palpitations, exercise intolerance Congestion-related: shortness of breath, fatigue/lack of energy Reporting of symptoms often not in concordance with objective presence of AF rhythm Suggests that this is not only an electrophysiological disorder, but that other factors, like emotional distress, might affect symptom perception, and maybe also recurrence of AF episodes

31. CoRPS Disease-specific patient-rated measures: Quality of life MeasureAcronymOriginItemsDomains Atrial Fibrillation Effect on QualiTy-of-LifeAFEQTUSA20(i) Symptoms (ii) Daily Activities (iii) Treatment Concern (iv) Treatment Satisfaction Atrial Fibrillation Quality of Life questionnaire AF-QoLSpain18(i) Psychological activity (ii) Physical activity (iii) Sexual activity Toronto AF Severity ScaleAFSSCanada14Subjective and objective ratings of AF disease burden: (i)Frequency (ii)Duration (iii)Severity of episodes There are many more...

32. CoRPS Disease-specific patient-rated measures: Anxiety and depression Still to come...

33. CoRPS Conclusions Prevalence of depression and anxiety in AF equivalent to other cardiac populations ≈ 1 in 4 patients Symptoms of depression and anxiety seem to be undertreated – underdetected??? Few large-scale prospective studies available Distress in AF patients likely has consequences for recurrence and mortality Need for developing disease-specific distress measures Need to identify these patients in clinical practice

34. CoRPS Can a nurse and a computer manage AF better than a heart doctor? Hendriks et al. ACC 2011; Abstract 3016-12 712 AF patients followed for 22 months Randomized to care in an AF-clinic model or to usual care (UC; cardiologist) Fewer patients in the AF-clinic group reached the primary endpoint: 51 (14.3%) versus 74 (20.8%) in the UC group o Heart-related deaths: AF-clinic = 1.1% versus UC = 3.9% o Heart related hospitalizations: AF-clinic = 13.5% versus UC = 19.1% Patient distress levels ??? No behavioral/psychological intervention trials in AF patients targeting distress...

35. CoRPS Living in a Device World: Focus on Recent Challenges and Tools to Improve Clinical Care for Patients with an Implantable Cardioverter Defibrillator Device Conference, 3-4 November 2011, Tilburg, the Netherlands Themes OVERCOMING THE SHOCK OF THE ICD ICD REGISTRIES AND THE INCLUSION OF THE PATIENT PERSPECTIVE DEACTIVATION OF THE ICD AND END OF LIFE ISSUES NEGLECTED SUBGROUPS CRT SELECTION AND RESPONSE THE DO’S AND DON’TS OF PATIENT COMMUNICATION SEXUALITY IN ICD PATIENTS BEHAVIORAL INTERVENTIONS LOOKING INTO THE FUTURE Selection of invited faculty Nico Blom (MD, PhD), Leiden University Medical Center, NL Matthew Burg (PhD), Yale School of Medicine, USA Viviane Conraads (MD, PhD), University Hospital Antwerpen, BE Dorothy Frizelle (PhD), University of Hull, UK Jens Brock Johansen, (MD, PhD), Odense University Hospital, DK Karl-Heinz Ladwig (MD, PhD), Helmholtz Institute, Munich, GE Mathias Meine (MD, PhD), University Medical Center Utrecht, NL Susanne S. Pedersen (PhD), CoRPS, Tilburg University, NL Samuel Sears (PhD), East Carolina University, USA Steen Pehrson (MD, PhD), Copenhagen University Hospital, DK Dominic Theuns (PhD), Erasmus Medical Center Rotterdam, NL More information available on: www.tilburguniversity.edu/device2011