Dear Editors,

I am writing to comment on the article published in the Journal of Cardiovascular Nursing on September 10, 2021, Volume 36, Issue 5, titled "Exploring Depressive Symptoms and Anxiety Among Patients With Atrial Fibrillation and/or Flutter at the Time of Cardioversion or Ablation."1 This article explored the challenges patients with atrial fibrillation and atrial flutter experience relating to depression and anxiety when pursuing a cardiac catheter ablation and/or cardioversion. I appreciate the work put into this study, but I am not surprised to learn there was little correlation with persistent anxiety/depression and reoccurrence of atrial fibrillation within 6 months post intervention.

On the basis of my experience working in an electrophysiology laboratory, depression and anxiety are very common and frequently problematic when patients arrive for their procedures. The frequency of preprocedural anxiety is reported to be approximately 80%, leading to hypertension and tachycardia, which can lead to bleeding and other complications.2 As the authors have also identified, this anxiety can have an impact on long-term mental health.1 However, I have not seen a rise in repeat ablations or cardioversions among the more anxious or depressed patients. I would like to highlight that patients who do not modify risk factors and lifestyle seem to have the greatest rates of atrial fibrillation recurrence. As supported in a recent article published in the Journal of Clinical Medicine, these risk factors include elevated body mass index, physical inactivity, hypertension, dyslipidemia, obstructive sleep apnea, and alcohol and tobacco use.3 For example, alcohol abstinence and bariatric surgery for morbid obesity in appropriate patients have demonstrated decreased atrial fibrillation burden and progression.

Although recurrence was essentially unrelated, I was most interested in the article's exploration of mental health and quality of life for this patient population with atrial fibrillation. The symptoms can be debilitating for some patients, and mental health needs to be supported as much as factors such as blood pressure and diabetes. After reading your article, I began to do some research of my own to identify anxiety and depression symptom management for these patients in the time surrounding their procedures. Many patients experienced heightened anxiety related to the anticipation of pain and threat of death.2 A comprehensive combination therapy has shown a positive impact on procedural pain and anxiety.2 The study conducted by Awaludin and associates2 designed and implemented the use of a smartphone-based nursing intervention model to promote consistency and accessibility. The smartphone application included music therapy, prayer, patient education, and hypnosis.2

I hope you will be pleased to know the impact the article prepared by Fitzgerald et al3 has had on myself and my electrophysiology team, as well as the preprocedural and postprocedural areas. Your authors have helped us become more aware of the mental health challenges our patients experience and how they may impact their quality of life and outcomes. We already began implementing music therapy for most procedures and prayer therapy preprocedure for agreeable patients. All too often, we become hyperfocused on our specialty and need to broaden our perspective to include our entire patient in our treatment. Thank you for your time and attention.

Sincerely,

Catherine Brown, BSN, RN, PMGT-BC

Jacksonville University Keigwin School of Nursing

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