Burnout linked to higher risk for abnormal heart rhythm

By Dr. Liji Thomas, MDJan 14 2020

A new study published in January 2020 in the European Journal of Preventive Cardiology shows that burnout could really cause your heart to fail as a result of an abnormal heart rhythm called atrial fibrillation (AF). This is the most common cardiac arrhythmia, affecting about 17 million people in Europe alone, and double that number worldwide. It can cause distressing chest symptoms including palpitations, shortness of breath and tiredness, or silently kill the patient. It is the most common cause of stroke in all Western nations.

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Though many risk factors for AF have been identified, these account for only about half of the cases. The presence of mental distress has been suggested to be one factor that could explain some of these cases.

Psychological distress could activate autonomic nervous system pathways such as the sympathetic nerves that trigger body-wide arousal and hypervigilance, stress and higher stress hormone levels. It can also make the hypothalamo-pituitary-adrenal axis more sluggish, while also affecting the renin-angiotensin-aldosterone system, which affects both the blood pressure and heartbeat. Finally, psychological distress could directly influence the activity of the pacemakers in the heart, called the sinoatrial and atrioventricular nodes, causing an irregular heartbeat.

What is already known?

Earlier studies on psychological health and new AF have not always been clear in their findings. The first analyses were carried out on mostly white people and showed no link between depression or chronic stress with AF. They did demonstrate that anger, hostility and tension were associated with AF in men alone.

A later study from Denmark shows that antidepressant usage is highly associated with AF. The Multi-Ethnic Study of Atherosclerosis shows a link between new AF and depression, but not with chronic stress, anger or anxiety. The current study was meant to evaluate the role of specific psychosocial measures that could show the presence of underlying psychological distress, in the causation of new AF, using data from the Atherosclerosis Risk in Communities (ARIC) study, including both whites and blacks. The scientists tested for the role of both vital exhaustion and negative emotions including anxiety, anger and depression.

Vital exhaustion is a condition of severe tiredness, with a feeling of being unmotivated and unanxious to go on, with increased irritability. A loss of vigor and excessive fatigue are the primary features of exhaustion, but not depression. According to researcher Parveen K. Garg, “Burnout can be any sort of stressor -- it doesn't necessarily have to be work. It can be personal stress, home or family tension. It's anyone who is chronically stressed and who suffers from chronic exhaustion.”

Vital exhaustion is a state in which the general inflammatory response is heightened, as well as a reduction in the tonic activity of the HPA which regulates the stress response of the body. Higher inflammation and stress responses are a killer combination.

The study

The researchers looked at over 11,400 people who were part of the Atherosclerosis Risk in Community Studies in 1987-89. The mean age was about 57 years. All had no evidence of AF at the beginning of the current study in 1990 to 1992. The participants were first evaluated for vital exhaustion at the start of the study in 1990-92 and assigned a score in the top quartile on the Vital Exhaustion Questionnaire (VEQ).

The scientists also asked about the use of antidepressants at the beginning to screen for mental disorders towards the affective disorder and anxiety end of the spectrum.

In addition, the subjects were all assessed for anger using the Spielberger Trait Anger Scale, and for social bonding using two instruments, the Interpersonal Support Evaluation List for social ties and the Lubben Social Network Scale for social network. The assessments were repeated in 1990–1992, 1993–1995, 1996–1998, 2011–2013, and 2016–2017. The participants were also followed up for any cardiovascular events.

The outcome of the study was the number of new cases of AF up to the year 2016, as detected by electrocardiogram, hospital discharge codes showing AF, and death certificates.

The findings

Individuals with higher VEQ scores were more commonly females, black, smokers, and had diabetes, coronary heart disease, left ventricular hypertrophy and were more likely to be on antidepressants and medications to control blood pressure. Metabolic parameters were more often abnormal, and these participants had lower educational levels on average.

The researchers found about 2,200 new cases of AF occurred during the follow-up period, which was on average 23.4 years. The risk for AF was estimated for those who had filled out the Vital Exhaustion Questionnaire and who were in the first quartile, after compensating for differences due to age, race, sex, education and height. The result showed a 45% higher risk for AF in this group, and a 37% increase for those who reported the use of antidepressants. The correlation with depression became non-significant after adjusting for other variables. Even after the risk estimate was further adjusted for the presence of other illnesses, it remained 20% higher. However, anger or lack of social bonding was not found to have any significant link with the development of AF.

Implications

The study shows an important association between the presence of vital exhaustion and new AF. While vital exhaustion is strongly linked with depression, there are some essential divergences. For one, vital exhaustion does not involve guilt and low self-esteem. Many earlier studies showed a strong correlation between vital exhaustion and depression but in the current study, this was absent following adjustment for multiple variables.

However, antidepressants may simply be a marker of mental ill-health in general and not just depression. Some antidepressants themselves cause arrhythmias, including the selective serotonin reuptake inhibitors and tricyclic antidepressants. Both are significantly linked with sudden cardiac death, though the increased risk is small. More study is required to elucidate the linkage between AF risk and antidepressant use.

Since the incidence of AF stands at about 8.5% in Europe, proving a significant association between vital exhaustion and AF could contribute towards reducing the health burden due to this condition. The ability to know whether it is possible to actually reduce AF rates by effectively detecting and treating vital exhaustion to is thus one to be sought diligently through research. This study will probably trigger others to understand whether cardiologists should focus on preventing burnout to reverse this association.