© 2005 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.
The relationship between personality, socio-economic factors, acute life stress and the development, spontaneous conversion and recurrences of acute lone atrial fibrillation
Department of Cardiology, University of Modena and Reggio Emilia Via del Pozzo, 71, 41100 Modena, Italy
Manuscript submitted 7 August 2003. Accepted after revision 6 February 2005.
*Corresponding author. Tel.:+39 59 4224043; fax: +39 59 4224323. E-mail address: mattioli.annavittoria{at}unimo.it (A.V. Mattioli).
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Abstract |
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AIMS: The present study was designed to establish the relationship between personality factors, socio-economic factors and acute life stress with development, spontaneous cardioversion and recurrences of acute lone atrial fibrillation.
METHODS: The study group consisted of 116 patients with lone atrial fibrillation cardioverted within 48 h of the onset of arrhythmia; they underwent a series of cognitive tests to evaluate acute psychological stress and personality type. The socio-economic status and other covariates (alcohol consumption, smoking, and body mass index) were investigated. A control group, age- and sex-matched, was selected and compared. In the logistic regression analysis, the presence of spontaneous conversion to sinus rhythm was used as the dependent variable. Independent variables were indicator variables representing categories of stress, Type A behaviour pattern, coffee consumption and body mass index. Variables considered for logistic analysis were only those with independent prognostic value.
RESULTS: Type A behaviour pattern was found in 23 (20%) patients with atrial fibrillation and in 11 (9%) controls (P < 0.001). The mean score among patients with atrial fibrillation was 8 ± 2.7, while in control subjects it was 5.5 ± 2. The mean acute life stress score among patients with atrial fibrillation was 56 ± 33, while in controls it was 34 ± 27 (P < 0.01). Spontaneous conversion of atrial fibrillation to sinus rhythm was observed in 72 patients (63%). In univariate analysis alcohol consumption, income, education and smoking habits did not affect spontaneous conversion. High coffee consumption (OR 0.3 95% CI 0.11–0.49; P < 0.008) and high body mass index were associated with a significantly greater risk of atrial fibrillation (OR 1.5 95% CI 1.2–1.7).
CONCLUSIONS: Type A behaviour pattern and acute life stress affect the development and spontaneous conversion of atrial fibrillation. Patients with acute stress showed the highest probability of spontaneous conversion followed by patients with Type A behaviour. Other socio-economic factors affect spontaneous conversion and recurrences of lone atrial fibrillation to a lesser extent.
Key Words: atrial fibrillation, conversion, psychology, acute stress life
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Introduction |
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Although the importance of psychosocial factors in the development of cardiac arrhythmias has been extensively debated, there are only a few studies that show how these factors contribute to the development of "minor arrhythmias". This is probably due to the many disciplines involved in the field, possibly resulting in the importance of epidemiological and pathophysiological observations being underestimated.
A relationship between psychological factors and arrhythmogenesis in humans has been reported [1
–3]. Disasters such as the 1994 Los Angeles earthquake have been associated with a fivefold increase in sudden death in patients with arrhythmias [4]. Everyday stress, such as driving and public speaking, produces ventricular ectopy and runs of ventricular tachycardia [5,6]. In addition there is a strong evidence for the arrhythmogenic potential of acute psychological stress in animals [1,7]. While interest in the effects of mental stress and personality on ventricular arrhythmias abounds in the cardiology literature, there has been relatively little interest in studying the effects on atrial fibrillation (A-Fib). The effects of acute life stress and personality on the development and on spontaneous conversion of A-Fib are unknown.
The aim of this prospective study was to establish whether there is an interrelationship between personality factors, socio-economic factors and acute life stress with development, spontaneous cardioversion and recurrences of acute lone A-Fib.
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Methods |
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Patient population
The study group consisted of 116 haemodynamically stable patients, hospitalized for an acute episode of lone A-Fib. Demographic and clinical characteristics of the patients are reported in Table 1.
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Inclusion criteria were that this was the first episode of lone A-Fib and that it occurred within 6 h of observation. The advent of A-Fib was defined as a new and clearly recognisable onset of symptoms including palpitations, dyspnoea or dizziness, or a combination of these symptoms. The diagnosis was confirmed by ECG.
Exclusion criteria were chronic A-Fib, any condition predisposing patients to A-Fib such as history of myocardial infarction, heart failure, hyperthyroidism, rheumatic heart disease, pulmonary embolism, systemic hypertension and reduced LV function (ejection fraction < 45%). No patients were receiving chronic therapy with antiarrhythmic drugs, and no one was taking a calcium antagonist or a beta-blocker. Patients were evaluated and telemetry monitoring technicians notified the investigators as soon as normal sinus rhythm was restored, and obtained electrocardiographic rhythm strips. All patients underwent Doppler echocardiography examinations [8].
The Ethical Committee of our University approved the study protocol and informed consent was obtained from all participants.
Case–control study
To evaluate the influence of Type A personality and acute life stress in the occurrence of A-Fib, a 1:1 case–control study was designed. Patients were compared with 116 age- and sex-matched control subjects, healthy outpatient volunteers (mean age 54 ± 6.5 years). Patients were selected with the help of family doctors, following a blinded list including only sex, age and body mass index. Interviews were used to obtain information on prior acute stress (between 0 and 30 days), to define Type A behaviour and to determine the socio-economic status and other covariates (alcohol consumption, smoking, and body mass index). Let Y be a binary variable, which distinguishes cases (Y = 1) from controls (Y = 0). Then Y corresponds to the occurrence of A-Fib.
Type A behaviour pattern
To assess Type A behaviour, the revised Minnesota Multiphasic Personality Inventory (MMPI-2) Type A Scale was used (Table 2) [9,10]. This questionnaire is made up of 19 items requiring true or false responses to questions about time urgency, competitiveness and hostile attitudes (see Appendix A). The questionnaire was administered in person by specially trained interviewers and has been validated [9,10]. A specialist in psychiatry analysed the data. High scorers on the Type A scale (>8) are described as hard-driving, fast-moving and work-oriented individuals who frequently became impatient, irritable and annoyed. For statistical analysis patients were arbitrarily categorized into four strata (0–4; 5–7; 8–10; >11).
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Life changes scaling
To assess acute psychological disturbances preceding A-Fib, Life Changes Scaling for the 1990s was used [11,
12]. The questionnaire consisted of 43 events relating to proportionate scaling life changes units (LCU) (see Appendix A). The interviewers focused on recent history, 30 days before and after the arrhythmic episode. The same method was applied to the control group. LCU range from 0 to 100 and patients were arbitrarily categorized into four strata (0–25; 26–50; 51–75; >75).
Others covariates
The body mass index was calculated and patients were categorized into three strata (<20; 21–27; >27). The prevalence of other covariates was assessed by a self-administered questionnaire. We investigated the following: espresso coffee consumption (0; 1–3; >3 cups of espresso per day), alcohol consumption (abstainers, lowest < 20 ml/day; intermediate between 21 and 50 ml/day; heavy > 50 ml/day), income (<$30,000 per year; between $30,000–$60,000 per year and >$60,000 per year), education (elementary; some high school; completed high school), smoking (never; former; irregular; packs per year).
Statistical analysis
Continuous variables are presented as means ± SD. Risk ratio (OR) and 95% confidence intervals (CI) were used to examine the association of A-Fib and other covariates. In logistic regression analysis, the presence of A-Fib was used as dependent variable, and independent variables were indicator variables representing covariates. Only variables of independent prognostic importance were retained in the final model. The following variables were included in the covariate-adjusted model: espresso coffee consumption, body mass index, alcohol consumption, income and smoking.
Kaplan–Meier recurrences of A-Fib curves were calculated for the high and low LCU groups. Three-month recurrences were those provided by Kaplan–Meier estimates. No patient was lost to follow-up. The association among variables was calculated with the use of Spearmen's rank correlation coefficient.
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Results |
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Type A behaviour pattern
Type A behaviour pattern (score > 8) was found in 23 (20%) patients with A-Fib and in 11 (9%) patients of the control group (P < 0.001). The mean Type A behaviour score among patients with A-Fib was 9 ± 1.07, while in control subjects it was 5.5 ± 2 (P < 0.001) (Table 2). In the first stratum there was a prevalence of control subjects, while in the other strata there was a prevalence of patients with A-Fib. (Table 3). In univariate analysis increasing levels of Type A behaviour were associated with a significantly greater risk of A-Fib.
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Stress
The mean LCU score among patients with A-Fib was 56 ± 33, while in control subjects it was 34 ± 27 (P < 0.01) (Table 2).
In the first and second strata there was a prevalence of control subjects (P < 0.01), while in the other two strata there was a prevalence of patients with A-Fib.
In univariate analysis, an increasing level of life changes units was associated with a significantly greater risk of A-Fib, and in the third and fourth strata the risk was more than twofold in patients with A-Fib (OR 3.1 95% CI 2.9–3.3).
Coffee (espresso cups)
The average coffee consumption among patients with A-Fib was 2.9 ± 1.4 per day and in the control group 2.1 ± 1.5 cups per day. In the third strata (>3 cups of espresso per day) there was a higher number of patients with A-Fib (Table 2).
In univariate analysis, an increasing level of coffee consumption was associated with a significantly greater risk of A-Fib (OR 1.74 95% CI 1.6–1.9, P < 0.001).
Body mass index
The mean body mass index score among patients with A-Fib was 25.33 ± 4.60 per day and in the control group 25.18 ± 3.9 (P = 0.78). In the first and second strata there was no difference between the two groups of patients while in the third strata (body mass index > 27) there was a prevalence of patients with A-Fib (Table 2).
In univariate analysis, an increasing level of body mass index was associated with a significantly greater risk of A-Fib (OR 1.5 95% CI 1.2–1.7).
Other covariates (Tables 2 and 3)
Alcohol consumption. No statistical difference between the two groups was observed in any strata.
Income. No statistical difference between the two groups was observed in any strata. In univariate analysis the covariate appears to be indifferent.
Education. No statistical difference between the two groups was observed in any strata.
Smoking. No statistical difference between the two groups was observed in any strata. In univariate analysis, we did not observe a significantly greater risk in any strata.
Spontaneous conversion of A-Fib
Spontaneous conversion of A-Fib to sinus rhythm within 48 h of the onset of symptoms was observed in 72 patients (63%), the remaining 44 patients underwent external DC shock for cardioversion.
In univariate analysis, alcohol consumption, income, education and smoking habits did not affect spontaneous conversion to sinus rhythm in any strata (Table 4).
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Body mass index
The univariate analysis included only patients with higher body mass index (>27), in which the difference between the two groups was significant (P = 0.016). In this analysis, the highest level of body mass index was associated with a significant reduction in the probability of spontaneous conversion to sinus rhythm (Table 4). Patients with higher BMI had slightly dilated left atria compared with patients with normal BMI and this could explain the low probability of spontaneous conversion [13]
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Coffee
The univariate analysis included patients with a higher consumption of coffee (>3 cups/day), in which the difference between the two groups showed a trend towards statistical significance (P = 0.06). In this analysis the highest consumption of coffee was associated with a significant reduction in the probability of spontaneous conversion to sinus rhythm (Table 4).
Life changes units
The univariate analysis was conducted only in patients with LCU > 50. The OR was 4.1 95% CI 3.9–4.2. We can conclude that patients with high LCU are more likely to convert spontaneously to sinus rhythm within 48 h of the onset of arrhythmia (Table 4).
Type A behaviour
The univariate analysis was conducted only in patients with the highest number of positive answers for personality A (>11). The OR was 2.4 (95% CI 2.2–2.6) (Table 4).
Multiple logistic regression analysis
In the logistic regression analysis, the presence of spontaneous conversion to sinus rhythm was used as the dependent variable. Independent variables were indicator variables representing categories of stress, Type A behaviour, coffee and body mass index (Table 5). Variables considered for logistic analysis were only those with independent prognostic value. Patients with acute stress showed the highest probability of spontaneous conversion followed by patients with Type A behaviour. High coffee consumption and high body mass index negatively affect spontaneous conversion.
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Follow-up
To estimate the influence of stress on the maintenance of sinus rhythm, patients were divided into two groups according to the median value of LCU. The first group (group A) consisted of 54 patients who had LCU > 56 and group B included 55 patients who had LCU < 56. Patients were followed up for three months. They were contacted by telephone every 10 days, if they were symptomatic they came for a visit and ECG recording; any recurrences of A-Fib were censored at that time.
We found 26 recurrences of A-Fib: four patients from group A and 22 patients from group B (P < 0.001). In patients who suffered from A-Fib as a consequence of stress, recurrences were significantly less frequent than in those who did not suffer from stress.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix A. Items on...AcknowledgementsReferences |
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In a case–control study, we observed that Type A personality, life changes units, coffee and body mass index were associated with greater risk of A-Fib. To the best of our knowledge this study is the first to examine the association between psychological personality and socio-economic factors and acute stress events in patients suffering from lone A-Fib. During the last three decades, epidemiological studies have noted a correlation between important life changes, such as bereavement and retirement and others with increased mortality from coronary artery disease [12,
14,15]. The relationship between acutely emotional events and sudden death was observed in 100 consecutive cases by Meyers and Dewar, who found that 23 victims had apparently experienced moderate or acute emotional stress during the 30 min preceding death [16]. Reich et al. [17] found that in 117 patients who were referred for antiarrhythmic management, 24 had experienced acute emotional disturbances during the 24 h preceding the life-threatening ventricular arrhythmia. In one study of 95,647 individuals observed for 4–5 years, the highest relative mortality occurred immediately after bereavement [15]. After the first month, the mortality rate returned to normal population levels. It would be interesting to establish whether A-Fib also increases in the immediate aftermath of other episodes of acute stress.
Spontaneous restoration of sinus rhythm
Spontaneous restoration of sinus rhythm was observed in 72 patients (63%). The probability of restoration of regular rhythm was higher in patients with more elevated life changes units. Similarly, patients with the highest Type A behaviour had more probability of converting to sinus rhythm. Body mass index and high consumption of coffee were associated with a significant reduction in the probability of spontaneous conversion. Previous data on spontaneous conversion of A-Fib to sinus rhythm have been obtained from small studies focusing on different types of antiarrhythmic treatment for promoting cardioversion [18,19]. In these studies spontaneous conversion occurred, respectively, in about 70% of patients [20], in 44% [21] and 46% in the Digitalis in Acute Atrial Fibrillation Study [22]. The positive influence of elevated life changes units and Type A behaviour on conversion to sinus rhythm is probably due to the fact that in these types of patients the arrhythmia was induced by an exaggerated cardiovascular reactivity of short duration.
Recurrences
Recurrences of A-Fib are very common. Generally speaking, it can be affirmed that about 50% of patients remain in sinus rhythm after the first two months following cardioversion [19]. In the present study, we observed 26 (23%) recurrences at two months. Patients who had higher life changes units experienced a significantly lower number of episodes. Patients with Type A personality had no significant increase in recurrences during the three months of follow-up. The impact of psychosocial factors in the pathogenesis of cardiovascular event is not of long duration: for example, in one study of 95,647 individuals observed for 4–5 years the highest relative mortality occurred after bereavement, but after three weeks mortality rates returned to normal population levels [15]. During the Los Angeles earthquakes of 1994 and after the first day of missile strikes on Israel, cases of sudden cardiac death rose sharply from the day preceding the catastrophes to the day of the stress-inducing events, but in a few days mortality rates returned to normal levels [4,23].
Pathophysiological mechanisms
Researchers have consistently noted an interrelationship between behavioural factors and arrhythmogenesis in humans and in animals [24–27]. Acute stress induces electrocardiographic alteration and induces an increase in QT dispersion that may facilitate arrhythmic manifestation [26]. The exact mechanisms underlying these effects on the action potential duration remain unclear, but it is possible that they are mediated by the sympathetic nervous system. This hypothesis is supported by the increase in circulating catecholamines in the aftermath of acute life stress [27] and by the observation that beta-adrenergic blockade prevents the arrhythmogenic effects of acute life stress [28,29]. Evidence suggests that Type A behaviour individuals are more likely to exhibit hypercholesterolaemia and high levels of circulating catecholamines [30] as well as diminished mononuclear leukocyte beta-adrenergic receptor function [31]. The data relating behavioural factors to arrhythmia therefore show the reliability of the effects, and identify excessive sympathetic activation as a major precipitating factor. The exact mechanism by which acute psychological disturbances may predispose to A-Fib is unknown. However, some possible mechanisms have been proposed. Mental stress increases autonomic sympathetic activation and the production of steroid and free fatty acids [32,33]. Death associated with acute psychological stress has been attributed to the imbalance between the autonomic parasympathetic and sympathetic systems with the overriding effect of the sympathetic [34].
In general, stimuli that provoke anger-like responses are especially likely to lead to abnormalities in rhythm [29]. Researchers have also related behavioural factors to arrhythmias in other experimental animals [35].
Limitations of the study
All information about socio-economic factors and acute life stress were collected at the time of hospitalization for cardioversion of arrhythmia. Results of this study may not be applicable to all patients with A-Fib because we selected only patients with idiopathic A-Fib, while the majority of patients with this supraventricular arrhythmia present with structural heart disease. However, the number of patients is large enough to draw information about the influence of stress and personality on the development of lone A-Fib.
Conclusions
The present study suggests that Type A behaviour pattern of personality and acute life stress affects the development and spontaneous conversion of A-Fib. Patients with acute stress showed the highest probability of spontaneous conversion followed by patients with Type A behaviour. Other socio-economic factors such as alcohol consumption, espresso coffee consumption and smoking affect spontaneous conversion and recurrences of A-Fib to a lesser extent.
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Appendix A. Items on the MMPI-2 Type A Scale |
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Type A scale (19 items)
- When people do me wrong, I feel I should pay them back if I can, just as a matter of principle.
- It makes me impatient to have people ask my advice or otherwise interrupt me when I am working on something important.
- I resent having anyone trick me so cleverly that I have to admit I was fooled.
- I have at times stood in the way of people who were trying to do something not because it amounted to much but because of the principle.
- I easily become impatient with people.
- I have often found people jealous of my good ideas, just because they have not thought of them first.
- I have at times had to be rough with people who are rude or annoying.
- There are certain people whom I dislike so much that I am inwardly pleased when they are caught for something they have done.
- It makes me nervous to have to wait.
- I am often inclined to go out of my way to win a point with someone who has opposed me.
- I am often sorry because I am so irritable and grumpy.
- I am usually very direct with people I am trying to correct or improve.
- I am often very irritable with people when they interrupt my work.
- Others tell me I eat too fast.
- At movies, restaurants, or sporting events, I hate to have to stand in line.
- I work very long hours even though my work doesn't require this.
- I get very irritable when people I depend on don't get their work done on time.
- I work best when I have a definite deadline.
- I always have too little time to get things done.
Legend: Yes always = score 5; sometimes = score 3; occasionally = score 2; never = score 0.
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Acknowledgements |
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We would like to thank Giulia Ricci Lucchi, Department of Cardiology, Ravenna, L. De Maria, Department of Emergency, Azienda Ospedaliera of Modena, Emma Tarabini Castellani, Department of Cardiology, Modena For their contribution.
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References |
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