Impact of Stress & Meditation on Atrial Fibrillation

Answer:

Stress is associated with deleterious behavioural & physiological phenomena which conspire to increase adverse cardiac remodelling and increase the risk of atrial fibrillation.

 

Meditation, mindfulness & breathing exercises alleviate symptoms of AF, improve quality of life & induce positive physiological adaptations which may even reduce absolute AF burden.

 

 

How does Stress impact Atrial Fibrillation?

 

• Chronic stress releases cortisol & activates the sympathetic nervous system which promotes activation of fibroblasts & inflammation processes, causing fibrofatty replacement of myocardium, adverse cardiac remodelling & increasing propensity to atrial fibrillation.

 

• Stress is also associated with comorbidities such as hypertension, & poor behaviours such as poor diet & exercise routines, which increase AF risk.

 

• In many cases, fluctuation in autonomic tone such as high sympathetic drive precedes an episode of paroxysmal AF, suggesting autonomic dysregulation in stress may also play a role in triggering AF episodes.

 

 

Meditation & Atrial Fibrillation

• Meditation, mindfulness & breathing exercises have the conceptual potential to alleviate some of the negative effects of stress on atrial fibrillation.
• Meditation & breathing exercises positively impact the autonomic regulation of the central nervous system.

 

Physiologic basis of Meditation benefits:

• Regular practice has been demonstrated to induce neuroplastic changes to brain structures associated with decision-making, self-control, emotional regulation and processing, memory, and learning. For example, it increases the density of grey matter in the prefrontal cortex associated with decision making & self-control while reducing the Amygdala volume associated with decreased stress & anxiety levels.

 

Thankfully, we have a randomised trial study which looked into this:

 

MENTAL-AF Trial Method

• 183 patients who underwent AF Ablation for Paroxysmal or Persistent AF were randomised to mental training Vs non-mental training for the first 3 months post-ablation.
• Mental training included at least two ≈10 minute sessions per week with an app called “Mindance”. Interventions included relaxation techniques to relieve physical and mental discomfort, progressive muscle relaxation, mindfulness & breathing exercises aimed to refine introspection.

 

RESULT:

• Mental training significantly alleviated symptom burden compared to AF ablation alone. This improvement didn’t occur until 2 months after PVI, & the trend remained consistent over 3 months.

 

• Enhanced symptoms profile as a result of mental training was an effect found across all sub-groups.

• Both Ablation alone & Ablation + Mental training improved AF-related QoL scores. However, whilst AF ablation alone did NOT improve general Quality of Life scores, the Mental training arm DID improve general QoL scores post ablation. This was driven largely by an improvement in the daily activity section of the score.

 

How did Mental training improve Symptoms & QoL?

• Consistent Mental training took 2 months to have a treatment effect. The improved QoL & Symptom Reduction was likely due to induced neuroplastic changes in brain structure which positively impacted the modulation of the cardioneural axis & autonomic regulation.

 

Improvement in AF symptoms may have been due to 3 causes:

1. Altered perception of AF symptoms due to mindfulness (Physiological reductions in Amygdala volumes & increased prefontal cortex grey matter density may have also played a role in this).
2. Reduction in AF burden due to improved autonomic regulation
3. Stress reduction

 

Similarly, Yoga has repeatedly demonstrated significant impacts on the cardiovascular system in past studies including:

• Improvement in heart rate variability (marker of mortality & pAF risk)
• Improvement in BP
• Improvement in stress scores, anxiety, depression & QoL.

 

 

An interesting question, is whether this reduction in symptom burden could have been due to a reduction in AF BURDEN?

 

 

Yoga has previously demonstrated an absolute reduction in AF burden

• Single centre studies have demonstrated x3 30minute yoga sessions per week reduces symptomatic & asymptomatic episodes of atrial fibrillation.
• Of course, confounding factors may be present such as patients who participate in yoga are more likely to eat well, exercise more, drink less etc. But is this a bad thing?

 

Physiologically, Yoga has been demonstrated to reduce systemic inflammation & markers of systemic stress, including:

1. Reduced cortisol
2. Reduced CRP & IL-6 (inflammatory markers)
3. Reduced endothelial dysfunction
4. Reduced allostatic load (cumulative physiological markers of stress)

 

• These physiological changes may be enough to explain the reduction in AF burden with yoga. One study even suggested that deep breathing was associated with a 50% reduction in PVC burden, highlighting the physiological impact meditative exercise can have on autonomically driven arrhythmias.

 

 

 

My Two Cents:

• Full disclosure, as an on-off participant in meditation, QiGong & TaiChi for many years now, I am personally invested in these practices and would love to see objective evidence showing how they benefit my life. I also like the idea that we can have a positive impact on our life by engaging in non-invasive behavioural changes.
• Despite my personal bias, I think there is much evidence to suggest that these practices induce positive neuroplastic changes to brain structures & ultimately improve autonomic regualtion as well as anxiety, depression, emotional regulation, & self control.
• MENTAL-AF & previous studies have demonstrated that mental training alleviates AF symptoms & improves QoL, even in the setting where AF ablation alone could not demonstrate significant improvement in QoL comapred to pre ablation.
• Physiological changes to the cardioneural axis induced by regular meditation & yogic practices may reduce the absolute burden of AF episodes, and there is certainly a body of literature which seems to suggest that this is the case.
• Whilst AF ablation is well established as the most effective tool in our arsenal in reducing AF burden & alleviating symptoms, we should not overlook combining this with non-invasive interventions such as yoga & mental training, which may positively impact our lives.

 

Thanks for tuning in :)
Cheers
Mitch & CPP Team

 

References:

• Lurz J, Hengelhaupt L, Unterhuber M, Stenzel L, Hilbert S, Schöber AR, Dinov B, Darma A, Dagres N, Hindricks G, Lurz P, Bollmann A. App-Based Mental Training to Reduce Atrial Fibrillation-Related Symptoms After Pulmonary Vein Isolation: MENTAL AF Trial. J Am Heart Assoc. 2024 Jun 4;13(11):e033500.
• Yetkin Ertan, Aksoy Yuksel, Yetkin Ozkan, Turhan Hasan. Beneficial effect of deep breathing on premature ventricular complexes: can it be related to the decrease in QT dispersion? Int. J. Cardiol. 2006 Nov 18;113 (3):417–8.
• Lakkireddy, D, Atkins, D, Pillarisetti, J. et al. Effect of Yoga on Arrhythmia Burden, Anxiety, Depression, and Quality of Life in Paroxysmal Atrial Fibrillation: The YOGA My Heart Study. JACC. 2013 Mar, 61 (11) 1177–1182.
• Akella K, Kanuri SH, Murtaza G, G Della Rocca D, Kodwani N, K Turagam M, Shenthar J, Padmanabhan D, Basu Ray I, Natale A, Gopinathannair R, Lakkireddy D. Impact of Yoga on Cardiac Autonomic Function and Arrhythmias. J Atr Fibrillation. 2020 Jun 30;13(1):2408.
• Yetkin Ertan, Aksoy Yuksel, Yetkin Ozkan, Turhan Hasan. Beneficial effect of deep breathing on premature ventricular complexes: can it be related to the decrease in QT dispersion? Int. J. Cardiol. 2006 Nov 18;113 (3):417–8.
• Segan L, Prabhu S, Kalman JM, Kistler PM. Atrial Fibrillation and Stress: A 2-Way Street? JACC Clin Electrophysiol. 2022 Aug;8(8):1051-1059