The Anxiety-AFib connection: A systematic review of mental health and arrhythmia interactions

Abstract

Background: Atrial fibrillation is the most common cardiac arrhythmia, which has effects that goes beyond the heart, often affecting mental health. Over the years, increasing evidence has highlighted a bidirectional connection between anxiety and atrial fibrillation. However, the connection between the two in clinical practice is vague.

Objective: This systematic review aims to investigate the relationship between anxiety and atrial fibrillation, including how anxiety might contribute to the onset and relapse of atrial fibrillation, how it may impact the treatment outcomes and its effects on the patient’s overall quality of life.

Methods: We conducted an extensive search of PubMed, Scopus, Embase, and Cochrane to systematically identify studies between 2020 and 2025. Adult patients with atrial fibrillation diagnosis who were assessed for anxiety were included using validated scales. A total of 84 articles met the inclusion criteria, with data extracted on anxiety measures, features of atrial fibrillation, clinical impact, and treatment effects.

Results: Among the reviewed studies, anxiety was both prevalent in AF patients and significantly associated with poorer clinical outcomes across the majority of included studies, though the strength and nature of associations varied across study designs and populations. Patients with higher levels of anxiety had a higher probability of recurrent atrial fibrillation, increased symptom burden, and lower health-related quality of life. Anxiety also influenced treatment outcomes and adherence, particularly regarding anticoagulation and ablation therapy. Notably, several interventions including catheter ablation and structured patient education were associated with reductions in anxiety and improvements in outcomes. Importantly, one Mendelian randomisation study found no causal relationship between anxiety and AF, while depression and panic disorder showed causal associations, underscoring the need for cautious interpretation of observational findings.

Conclusion: Anxiety and atrial fibrillation appear to share a complex, predominantly bidirectional association. While most observational studies support a link between anxiety and worse AF-related outcomes, evidence from Mendelian randomisation does not confirm a causal role for anxiety in AF onset, suggesting that residual confounding may partly account for observational associations. Addressing mental health in AF care is nonetheless clinically important. Incorporating psychological assessment and support into AF management may reduce symptom burden and improve treatment adherence and quality of life. Further research, particularly longitudinal interventional studies using standardised instruments, is required to guide more comprehensive, patient-centred care.