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Randomized Controlled Trial
. 2025 Aug;93(8):527-539.
doi: 10.1037/ccp0000961.

The role of cardiac-related fear, hypervigilance, and avoidance behavior in exposure-based cognitive behavioral therapy for atrial fibrillation: A mediation analysis based on a randomized controlled trial

Josefin Särnholm  1 , Erland Axelsson  2 , Helga Skúladóttir  3 , Marianne Bonnert  4 , Maria Bragesjö  4 , Christian Rück  4 , Susanne S Pedersen  5 , Frieder Braunschweig  3 , Brjánn Ljótsson  1
Affiliations
Randomized Controlled Trial

The role of cardiac-related fear, hypervigilance, and avoidance behavior in exposure-based cognitive behavioral therapy for atrial fibrillation: A mediation analysis based on a randomized controlled trial

Josefin Särnholm et al. J Consult Clin Psychol. 2025 Aug.

Abstract

Objective: Atrial fibrillation (AF) is associated with distressing symptoms and diminished quality-of-life (QoL). In a recent randomized controlled trial (RCT), online exposure-based cognitive behavioral therapy (AF-CBT) targeting symptoms preoccupation, i.e., cardiac-related fear, hypervigilance, and avoidance behavior, in patients with symptomatic paroxysmal (i.e., intermittent) AF significantly improved AF-specific QoL relative to a control group receiving standardized AF education. This study aims to investigate whether a reduction in symptom preoccupation can explain the treatment effect of AF-CBT on self-rated AF symptoms and AF disability.

Method: We used data from a recent RCT involving 127 patients diagnosed with paroxysmal AF, randomized to undergo AF-CBT over 10 weeks (n = 65) or to receive AF education (n = 62). Two putative mediators, cardiac-related fear/hypervigilance and avoidance behavior, along with a competing mediator, perceived stress, were measured weekly. Outcome variables included self-rated AF symptoms and AF-related disability.

Results: Results from parallel process growth models indicated that the reduction in symptom preoccupation-but not perceived stress-mediated the controlled effect of AF-CBT on both AF symptoms and disability. In cross-lagged panel models, of the within-individual week-by-week change, a reduction in cardiac-related fear predicted subsequent improvement in AF symptoms, while a decrease in avoidance behavior predicted subsequent improvement in AF-related disability.

Conclusions: Our findings suggest that symptom preoccupation plays a significant role in AF symptoms and disability and can be effectively targeted by online AF-CBT. Integrating this understanding into the clinical management of AF holds promise for improving patient outcomes. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Trial registration: ClinicalTrials.gov NCT03378349.

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