Effect of β-blockers on triggering of symptomatic atrial fibrillation by anger or stress

Heart Rhythm. 2019 Aug;16(8):1167-1173. doi: 10.1016/j.hrthm.2019.03.004. Epub 2019 Jun 3.


Background: Anger and stress can trigger episodes of atrial fibrillation (AF) in patients with a history of AF.

Objective: The purpose of this study was to determine whether β-blockers can protect against emotionally triggered AF.

Methods: In this prospective, controlled, electronic diary-based study of emotions preceding AF, patients with a history of paroxysmal or persistent AF (N = 91) recorded their rhythm on event monitors at the time of AF symptoms and completed a diary entry querying mood states (eg, anger and stress) for the preceding 30 minutes (pre-AF "case period") for 1 year. Also, patients underwent monthly 24-hour Holter monitoring during which they were prompted to complete a diary entry twice per hour. Diaries recorded during sinus rhythm comprise controls. Patients' exposure to each emotion was compared between the pre-AF case period and control periods by using generalized estimating equation modeling, as well as interactions between β-blocker use and emotion tested.

Results: Sixty percent were prescribed β-blockers. A total of 163 symptomatic AF episodes (in 34 patients) and 11,563 Holter-confirmed sinus rhythm control periods had associated diary data. Overall, the likelihood of an AF episode was significantly higher during anger or stress. This effect, however, was significantly attenuated in patients on β-blockers (odds ratio 22.5; 95% confidence interval 6.7-75.4, P < .0001 for patients not prescribed β-blockers vs odds ratio 4.0, 95% confidence interval 1.7-9.5, P = .002 for those prescribed β-blockers; P = .02 for the interaction). Exclusion of patients on sotalol did not affect findings.

Conclusion: Anger or stress can trigger AF, but use of β-blockers greatly attenuates this deleterious physiological response.

Keywords: Anger; Atrial fibrillation; Stress; Triggering; β-Blocker.

Publication types

  • Controlled Clinical Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Anger*
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / physiopathology
  • Atrial Fibrillation / psychology
  • Electrocardiography, Ambulatory / methods
  • Emotions / physiology*
  • Female
  • Heart Rate / drug effects*
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Stress, Psychological / complications*
  • Stress, Psychological / physiopathology
  • Stress, Psychological / psychology


  • Adrenergic beta-Antagonists