Rhythm and Blues: Atrial Fibrillation, Depression, and the Autonomic Nervous System

The treatment of atrial fibrillation (AF) is compounded by its common coexistence with depression. Autonomic dysfunction has been described in both conditions, which may represent a shared target for treatment. A narrative review was conducted to synthesize the literature surrounding depression, AF, autonomic dysfunction characterized using heart rate variability, and antidepressant medication. Invasive autonomic modulation in AF has been studied as part of catheter ablation for AF. Changes in autonomic indices after catheter ablation have been associated with improved quality of life and reduced anxiety scores in the short term. Treating depression in AF using clinically available selective serotonin reuptake inhibitor antidepressants may reduce excessive changes in heart rate variability and possibly autonomic dysfunction seen in AF. These agents may also improve compliance with lifestyle changes that are critical in the management of AF. These agents have a good safety track record in the coronary artery disease and heart failure populations but have not been systemically studied in arrhythmia likely secondary to concurrent administration of class III antiarrhythmic medications. However, effects on QT interval vary within this drug class and are not as large as those exerted by tricyclic antidepressants. Additionally, behavioral treatment of depression in AF has been shown to reduce symptom perception and health care utilization despite stable AF burden. In conclusion, effective treatment of depression may have direct benefits on AF treatment via autonomic modulation and indirect benefits via enhanced risk factor management and reduced symptom perception.