The Effects of Chronic Exercise Training in Individuals With Permanent Atrial Fibrillation: A Systematic Review

Leisure-time physical activity and the incidence of atrial fibrillation in senior adults: a prospective cohort study

OBJECTIVE

Whether physical activity could reduce the risk of atrial fibrillation (AF) remains unclear. This study was to investigate the relationship of leisure-time physical activity (LTPA) with AF incidence among Chinese older adults.

METHODS

A total of 3253 participants aged ≥60 years from the Guangzhou Heart Study were successfully followed between March 2018 and September 2019. LTPA was assessed using a modified Global Physical Activity Questionnaire. AF was ascertained by 12-lead electrocardiograms, 24-hour single-lead Holter and clinical examination. The Cox proportional hazards model was used to the estimate hazard ratio (HR) and 95% confidence interval (CI) after adjustment for confounders, and the population-attributable fraction (PAF) was estimated.

RESULTS

A total of 76 (2.34%) new-onset cases of AF were identified during a median of 31.13 months of follow-up. After adjustment for confounders, subjects who had LTPA at least 10.0 metabolic equivalent (MET)-hours/week had a 55% lower risk of developing AF (HR: 0.45, 95%CI: 0.25-0.81), and at least 20 MET-hours/week reduced the risk by 45% (HR: 0.55, 95%CI: 0.34-0.92). At least 11% (PAF: 11%, 95%CI: 0%-20%) or 14% (PAF: 14%, 95%CI: 0%-26%) of AF cases could be avoided, respectively, if the subjects do LTPA at least 10 MET-hours/week or 20 MET-hours/week. A significant exposure-response trend was also observed between LTPA and AF risk (Plinear-trend = 0.002). For a specific LTPA, doing housework was associated with a 43% reduced risk, while engaging in ball games was associated with an increased risk.

CONCLUSION

This prospective cohort study indicated that a higher LTPA volume was associated with a lower AF risk in Chinese older adults.

Sex Differences in Physical Activity Levels and Sitting Time in Patients With Atrial Fibrillation

PURPOSE

While research demonstrates low levels of physical activity (PA) among adults living with atrial fibrillation (AF), there is limited evidence investigating sex differences in moderate to vigorous intensity physical activity (MVPA) and sedentary time in this population. The primary aim was to examine sex differences in MVPA levels and sitting time between women and men with AF. Secondary aims explored sex differences in sociodemographic factors, outcome expectations, and task self-efficacy toward PA levels.

METHODS

This was a subanalysis of the CHAMPLAIN-AF cohort study. Women and men with AF completed a survey, including the Short-Form International Physical Activity Questionnaire.

RESULTS

A total of 210 women (median = 66.0 yr: 95% CI, 63.5-68.0) and 409 men (median = 66.0 yr: 95% CI, 64.0-67.0) were included. No sex differences were observed in median weekly MVPA (60 min/wk: 95% CI, 0-120 in women vs 120 min/wk: 95% CI, 85-150 in men) and daily sitting time (5.5 hr/d: 95% CI, 5.0-6.0 in women vs 6.0 hr/d: 95% CI, 5.0-6.0 in men). Women engaged in significantly less vigorous-intensity PA than men ( P = .03) and demonstrated significantly lower task self-efficacy ( P < .01). Significant positive correlations in PA levels with outcome expectations (mostly weak) and task self-efficacy (mostly strong) were observed in both sexes.

CONCLUSION

Most women and men with AF did not meet the global MVPA guidelines but met the sitting time recommendation. Women presented with lower vigorous-intensity physical activity levels and confidence than men. Strategies to increase physical activity behavior, considering sociodemographic factors and task self-efficacy, are needed and may differ between sexes.

Is breathing frequency a potential means for monitoring exercise intensity in people with atrial fibrillation and coronary heart disease when heart rate is mitigated?

PURPOSE

Moderate-intensity aerobic exercise is safe and beneficial in atrial fibrillation (AF) and coronary heart disease (CHD). Irregular or rapid heart rates (HR) in AF and other heart conditions create a challenge to using HR to monitor exercise intensity. The purpose of this study was to assess the potential of breathing frequency (BF) to monitor exercise intensity in people with AF and CHD without AF.

METHODS

This observational study included 30 AF participants (19 Male, 70.7 ± 8.7 yrs) and 67 non-AF CHD participants (38 Male, 56.9 ± 11.4 yrs). All performed an incremental maximal exercise test with pulmonary gas exchange.

RESULTS

Peak aerobic power in AF ( V ˙ O2peak; 17.8 ± 5.0 ml.kg-1.min-1) was lower than in CHD (26.7 ml.kg-1.min-1) (p < .001). BF responses in AF and CHD were similar (BF peak: AF 34.6 ± 5.4 and CHD 36.5 ± 5.0 breaths.min-1; p = .106); at the 1st ventilatory threshold (BF@VT-1: AF 23.2 ± 4.6; CHD 22.4 ± 4.6 breaths.min-1; p = .240). % V ˙ O2peak at VT-1 were similar in AF and CHD (AF: 59%; CHD: 57%; p = .656).

CONCLUSION

With the use of wearable technologies on the rise, that now include BF, this first study provides an encouraging potential for BF to be used in AF and CHD. As the supporting data are based on incremental ramp protocol results, further research is required to assess BF validity to manage exercise intensity during longer bouts of exercise.

Managing With Atrial Fibrillation: An Exploratory Model-Based Cluster Analysis of Clinical and Personal Patient Characteristics

Background

Examining characteristics of patients with atrial fibrillation (AF) has the potential to help in identifying groups of patients who might benefit from different management approaches.

Methods

Secondary analysis of online survey data was combined with clinic referral data abstraction from 196 patients with AF attending an AF specialty clinic. Cluster analyses were performed to identify distinct, homogeneous clusters of AF patients defined by 11 relevant variables: CHA2DS2-VASc score, age, AF symptoms, overall health, mental health, AF knowledge, perceived stress, household and recreation activity, overall AF quality of life, and AF symptom treatment satisfaction. Follow-up analyses examined differences between the cluster groups in additional clinical variables.

Results

Evidence emerged for both 2- and 4-cluster solutions. The 2-cluster solution involved a contrast between patients who were doing well on all variables (n = 129; 66%) vs those doing less well (n = 67; 34%). The 4-cluster solution provided a closer-up view of the data, showing that the group doing less well was split into 3 meaningfully different subgroups of patients who were managing in different ways. The final 4 clusters produced were as follows: (i) doing well; (ii) stressed and discontented; (iii) struggling and dissatisfied; and (iv) satisfied and complacent.

Conclusions

Patients with AF can be accurately classified into distinct, natural groupings that vary in clinically important ways. Among the patients who were not managing well with AF, we found 3 distinct subgroups of patients who may benefit from tailored approaches to AF management and support. The tailoring of treatment approaches to specific personal and/or behavioural patterns, alongside clinical patterns, holds potential to improve patient outcomes (eg, treatment satisfaction).

Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship

Atrial fibrillation (AF) is the most common sustained arrhythmia in clinical practice, and it is an enormous burden worldwide because of its high morbidity, disability and mortality. It is generally acknowledged that physical activity (PA) is strongly associated with a significant reduction in the risk of cardiovascular (CV) disease and all-cause mortality. Moreover, it has been observed that moderate and regular physical activity has the potential to reduce the risk of AF, in addition to improving overall well-being. Nevertheless, some studies have associated intense physical activity with an increased risk of AF. This paper aims to review the main related literature to investigate the association between PA and AF incidence and draw pathophysiological and epidemiological conclusions.

Cost-effectiveness analysis of digital therapeutics for home-based cardiac rehabilitation for patients with atrial fibrillation after catheter ablation

Background

In recent years, numerous guidelines and expert consensuses have recommended that digital technologies and products, such as digital therapeutics (DTx), be incorporated into cardiac rehabilitation (CR).

Objective

The study aims to compare the cost-effectiveness of DTx for home-based CR (HBCR) with that of the conventional HBCR for patients with atrial fibrillation (AF) after catheter ablation in a real-world clinical setting.

Methods

Based on a single-center, prospective, blinded, randomized, parallel controlled trial of DTx-based HBCR for AF patients after catheter ablation, 100 AF patients undergoing catheter ablation were selected and randomized at a 1:1 ratio into a UC group (conventional HBCR) and DT group (DTx-based HBCR). The intervention lasted for 12 weeks. Medical cost data and clinical efficacy data (VO2max) were acquired from trial data. Effect data (QALYs, anxiety and depression status, health beliefs related to cardiovascular disease, and exercise self-efficacy) were obtained from a patient questionnaire. The cost-effectiveness analysis was conducted to assess the economic benefits of DTx-based HBCR versus conventional HBCR, and the robustness of the results was verified by sensitivity analysis.

Results

In the DT group (n = 49), the mean QALYs increased 0.119 ± 0.09, VO2max increased 9.3 ± 8.0 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 75,080.55 ± 19,746.62 CNY. In the UC group (n = 48), the mean QALYs increased 0.077 ± 0.06, VO2max increased 4.9 ± 6.6 mL/(min*kg), anxiety, depression, health belief, and exercise self-efficacy had improved, and the total medical cost was 73,972.66 ± 16,582.04 CNY. The difference in the medical cost was 1107.89 CNY, and the incremental cost-effectiveness ratio was 33,572.42 CNY/QALY, which was lower than the willingness-to-pay threshold of 85,698 CNY (China's per capita GDP in 2022).

Conclusion

DTx-based HBCR is more effective and cost-effective than conventional HBCR.

The Physical Activity Levels and Sitting Time of Adults Living with Atrial Fibrillation – The CHAMPLAIN-AF Study

Background

Methods

Results

Conclusions

A novel model of home-based, patient-tailored and mobile application-guided cardiac telerehabilitation in patients with atrial fibrillation: A randomised controlled trial

OBJECTIVE

To assess the effectiveness of tele-monitored cardiac rehabilitation in patients who have undergone ablation for atrial fibrillation.

DESIGN

Single-centre, prospective, assessment-blinded, randomised controlled trial.

SETTING

Domiciliary rehabilitation with support from a tertiary care hospital.

SUBJECTS

One hundred patients who underwent ablation for atrial fibrillation were recruited.

INTERVENTIONS

Participants were randomly allocated to a 12-week standard rehabilitation treatment (control group) or a comprehensive, domiciliary, mobile application-guided and tele-monitored cardiac rehabilitation program (intervention group) in a 1:1 fashion.

MAIN OUTCOME MEASURES

The primary endpoint was the improvement in V_O2peak. The secondary outcomes included adherence, physical activity, beliefs related to cardiovascular disease and exercise self-efficacy.

RESULTS

Ninety-seven patients completed follow-up. The mean V_O2peak increased significantly in both the intervention group (n = 49) (baseline vs 12 weeks: 19.1 ± 4.7 vs 27.3 ± 5.6 ml/(min kg), P < 0.01) and the control group (n = 48) (baseline vs 12 weeks: 18.7 ± 4.9 vs 22.9 ± 6.3 ml/(min kg), P < 0.01). The results of the between-group analysis of aerobic capacity were significantly in favour of the intervention group. During the 12-week program, patients in the intervention group exhibited better adherence than those in the control group. Moreover, self-reported physical activity improved more in the intervention group than in the control group, as did the beliefs related to cardiovascular disease and exercise self-efficacy (all P < 0.01).

CONCLUSIONS

Our domiciliary, mobile application-guided and tele-monitored cardiac rehabilitation program could lead to a more significant improvements in physical fitness, adherence and health beliefs than standard cardiac rehabilitation in patients who have undergone ablation for atrial fibrillation.

Atrial fibrillation and autonomic nervous system: A translational approach to guide therapeutic goals

The autonomic nervous system (ANS) is known to play an important role in the genesis and maintenance of atrial fibrillation (AF). Biomolecular and genetic mechanisms, anatomical knowledges with recent diagnostic techniques acquisitions, both invasive and non-invasive, have enabled greater therapeutic goals in patients affected by AF related to ANS imbalance. Catheter ablation of ganglionated plexi (GP) in the left and right atrium has been proposed in varied clinical conditions. Moreover interesting results arise from renal sympathetic denervation and vagal nerve stimulation. Despite all this, in the scenario of ANS modulation translational strategies we necessary must consider the treatment or correction of dynamic factors such as obesity, obstructive sleep apnea, lifestyle, food, and stress. Finally, new antiarrhythmic drugs, gene therapy and "ablatogenomic" could be represent exciting future therapeutic perspectives.

Efficacy of Physical Exercise on the Quality of Life, Exercise Ability, and Cardiopulmonary Fitness of Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Objective: Physical exercise is recommended to help prevent lifestyle diseases. The present study was designed to quantify the efficacy of physical exercise on the quality of life (QoL), exercise ability and cardiopulmonary fitness of patients with atrial fibrillation (AF).

Method: A comprehensive systematic literature search was performed in Medline, Embase, Cochrane Library, Web of Science and PubMed databases (from 1970 to December 1st, 2019) for randomized controlled trials (RCTs) comparing physical exercise combined with AF routine treatments to routine treatments alone. The meta-analysis was conducted following PRISMA guidelines. Our main outcomes were QoL (measured by the Short-Form 36 scale, SF-36), exercise ability (measured by the 6-min walk test, 6MWT) and cardiopulmonary fitness (measured by peak oxygen uptake and resting heart rate). Quality assessments were conducted using the Cochrane Collaboration tool.

Results: Twelve trials involving 819 patients met the criteria for analysis. The results showed that physical exercise improved the QoL by enhancing physical functioning [standardized mean difference (SMD) = 0.63, 95%CI: 0.18–1.09; p = 0.006], general health perceptions (SMD = 0.64, 95%CI: 0.35–0.93; p < 0.001) and vitality (SMD = 0.51, 95%CI: 0.31–0.71; p < 0.001); increased exercise ability by improving the 6MWT performance (SMD = 0.69, 95%CI: 0.19–1.119; p = 0.007); and enhanced peak VO₂ (SMD = 0.37, 95%CI: 0.16–0.57; p < 0.001) while reducing resting heart rate (SMD = −0.39, 95%CI: −0.65 to −0.13; p = 0.004). In addition, meta-regression analysis showed that training mode (p_{physicalfunctioning} = 0.012, p_{generalhealthperceptions} = 0.035) and training duration (p = 0.047) were the main factors of an intervention that influenced the effect size. Following sub-group analysis, we found that aerobics, Yoga and longer training durations (≥60 min) showed larger improvements.

Conclusion: In summary, our meta-analysis shows that physical exercise has a positive effect on the QoL, exercise ability and cardiopulmonary fitness in AF patients. When physicians offer exercise recommendations to AF patients, they should consider both the training mode and training duration to achieve maximum results.

Physical activity and serious adverse events in patients with atrial fibrillation and/or atrial flutter treated with catheter ablation

BACKGROUND

Atrial fibrillation (AF) and atrial flutter (AFL) are cardiac arrhythmias associated with cardiovascular morbidity. Physical activity (PA) can trigger AF and AFL recurrence, but can also improve physical functional capacity in this patient group. Guidelines do not include concrete recommendations regarding PA for this patient group.

OBJECTIVE

To assess the impact of the level of PA on risk of serious adverse events (SAEs) in patients with AF and/or AFL treated with catheter ablation.

METHODS

A prospective cohort study including 462 patients with AF and/or AFL treated with catheter ablation from the CopenHeart Survey. The International Physical Activity Questionnaire (IPAQ) was used to explore patients' self-reported level of PA. SAEs were identified in the Danish National Patient Register and the Danish Civil Registration System one year after study onset. Cox regression analysis was carried out to assess the risks of SAE.

RESULTS

During the one-year follow-up period, 98 patients (21.8%) experienced at least one SAE. Patients with a moderate-high PA level had a 36% lower risk of experiencing SAEs during the follow-up period, compared to patients in the low PA group, after adjusting for confounders.

CONCLUSION

A moderate-high vs. low level of PA was found to be associated with a lower incidence of SAEs in patients undergoing AF and/or AFL ablation.

Exercise Testing and Exercise Rehabilitation for Patients With Atrial Fibrillation

INTRODUCTION AND PURPOSE

Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increasing prevalence with advancing age. It is associated with dyspnea, exercise intolerance, and increased risk for clinical events, especially stroke and heart failure. This article provides a concise review of exercise testing and rehabilitation in patients with persistent or permanent AF.

CLINICAL CONSIDERATIONS

The first goal in the treatment of AF is to reduce symptoms (eg, palpitations) and a fast ventricular rate. The second goal is to reduce the risk of a stroke. Exercise testing and rehabilitation may be useful once these goals are achieved. However, there are no large, randomized exercise training trials involving patients with AF, and what data are available comes from single-site trials, secondary analyses, and observational studies.

EXERCISE TESTING AND TRAINING

There are no specific indications for performing a graded exercise test in patients with AF; however, such testing may be used to screen for myocardial ischemia or evaluate chronotropic response during exertion. Among patients with AF, exercise capacity is 15% to 20% lower and peak heart rate is higher than in patients in sinus rhythm. Exercise rehabilitation improves exercise capacity, likely improves quality of life, and may improve symptoms associated with AF. Whole-body aerobic exercise is recommended.

SUMMARY

Atrial fibrillation is a common cardiac condition and in these patients, exercise rehabilitation favorably improves exercise capacity. However, prospective randomized controlled trials are needed to better define the effects of exercise training on safety; quality of life; clinical outcomes; and central, autonomic, and peripheral adaptations.

The effect of cardiac rehabilitation at 4 weeks postoperatively on quality of life in patients treated with totally thoracoscopic ablation

There is a lack of evidence on the effect of exercise-based cardiac rehabilitation (EBCR) in patients treated with total thoracoscopic ablation (TTA) for atrial fibrillation (AF). Our study investigated the efficacy and safety of postoperative exercise intervention in patients recovering from TTA. Twenty-four patients participated in the study, and were divided into the two groups, exercise group (EG) (n=12) and control group (n= 12). Patients in EG performed the exercise intervention including the aerobic and resistance exercise program twice a week for 8 weeks, which was used as a hospital-based cardiac rehabilitation for the out-patient. A cardiopulmonary exercise test was administered to evaluate aerobic exercise capacity, and qualitative aspect of patient’s life was assessed using the Short Form 36 questionnaires to compare pre and postoperative wellness of patient’s life. Although there was an increase of VO_2peak (peak oxygen uptake) after exercise intervention, no significant improvement was found (P=0.055). Two of 4 physical health scores (role-physical, P=0.013 and general health, P=0.05) and three of four mental health scores (vitality, P=0.027, social function, P=0.016, and mental health, P=0.003) were significantly improved after 8 weeks of EBCR. Each summarized scale in the physical (P=0.022) and mental (P= 0.004) survey section was also significantly improved in postoperative assessment compared to the preoperative one. In this context, we concluded that EBCR initiated at the time point of 4th week after TTA operation can guarantee the secure postoperative physical activity, and the 8 weeks of EBCR can effectively improve the quality of life in AF Patients.

Exercise Training in Heart Failure Patients With Persistent Atrial Fibrillation: a Practical Approach

Persistent AF is present in at least 20 % of patients with chronic heart failure (CHF) and is related to a poor prognosis and more severe cardiac arrhythmias. CHF and AF share a common pathophysiology and can exacerbate one another. Exercise programmes for people with CHF have been shown to improve aerobic capacity, prognosis and quality of life. Given that patients with both CHF and AF show greater impairment in exercise performance, exercise training programmes have the potential to be highly beneficial. Optimal clinical evaluation using a cardiopulmonary exercise test should be performed before starting a training programme. Heart rate should be calculated over a longer period of time In patients with CHF and AF than those in sinus rhythm. The use of telemetry is advised to measure HR accurately during training. If telemetry is not available, patients can be safely trained based on the concomitant workload. An aerobic exercise training programme of moderate to high intensity, whether or not combined with strength training, is advised in patients with CHF and AF. Optimal training modalities and their intensity require further investigation.

The Effects of Cardiac Rehabilitation in Patients With Atrial Fibrillation: A Systematic Review

BACKGROUND

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is associated with substantial morbidity and mortality. Clinical guidelines for managing patients with AF do not include a referral to cardiac rehabilitation (CR) at present, although it is routine for most other cardiovascular conditions. The number of studies evaluating the impact of CR on the health of patients with AF is growing, but there has been no consolidation of the findings. The objective of this systematic review was to evaluate the impact of CR programs on physical and mental health outcomes in patients with all forms of AF.

METHODS

Six electronic databases were searched to identify all studies that reported on the impact of CR in patients with AF. Searching identified 5771 potential articles, of which 12 were included. The physical health outcomes evaluated included cardiometabolic health indicators, aerobic and functional capacity, severity of symptoms, recurrence of AF, hospitalizations, and mortality. The mental health outcomes assessed included quality of life, anxiety, depression, and quality of sleep.

RESULTS

The limited evidence supports the use of CR to improve cardiometabolic health indicators and aerobic and functional capacity in patients with AF. The current evidence suggests that prominent improvements in aerobic fitness are associated with lower risk of hospitalization and mortality. The conflicting mental health findings may be due to the varying severity of AF and or modes of exercise interventions.

CONCLUSIONS

Gaps in the research identified the need for greater rigor in the reporting of intervention details, outcomes, and statistical methodology; sex- and gender-based analyses; and effectiveness trials. This review serves as a call to action for more work globally on this important area.

Excessive exercise in endurance athletes: Is atrial fibrillation a possible consequence?

Moderate physical activity levels are associated with increased longevity and lower risk of atrial fibrillation (AF). However, the relative risk of lone AF is 3-5-fold higher in intensive endurance-trained athletes compared with healthy adults. There is growing concern that "excessive" endurance exercise may promote cardiac remodelling, leading to long-term adverse consequences. The pathogenesis of exercise-induced AF is thought to arise from an interplay of multiple acute and chronic factors, including atrial enlargement, pro-fibrotic tendency, high vagal tone, and genotypic profile, which collectively promote adverse atrial remodelling. Clinical management of athletes with AF, while challenging, can be achieved using various strategies that may allow continued, safe exercise. Based on the overall risk-benefit evidence, it is premature to suggest that excessive exercise is unsafe or should be curtailed. Evidence-based assessment and treatment guidelines are required to ensure optimal and safe exercise among the growing number of endurance athletes with AF.

Effects of exercise training on exercise capacity, cardiac function, BMI, and quality of life in patients with atrial fibrillation: a meta-analysis of randomized-controlled trials

Exercise training has become part of the standard care for patients with cardiovascular disease. We investigated the effects of exercise training on exercise capacity, cardiac function, BMI, and quality of life in patients with atrial fibrillation (AF). We searched for randomized-controlled trials of supervised exercise training versus care without exercise training (the control) in patients with permanent or nonpermanent AF published up to November 2016. Standard mean differences (SMD) or mean differences (MD), and 95% confidence intervals (CIs) were calculated using random-effect models. We identified 259 trials, and after an assessment of relevance, five trials with a combined total of 379 participants were analyzed. In AF patients, exercise training significantly improved exercise capacity and left ventricular ejection fraction compared with the control (SMD: 0.91, 95% CI: 0.70 to 1.12; MD: 4.8%, 95% CIs: 1.56 to 8.03, respectively). Compared with the control, exercise training also significantly reduced BMI (MD: -0.47 kg/m, 95% CIs: -0.89 to -0.06) and significantly improved scores in the 'general health' and 'vitality' sections of the 36-item Short Form Health Status Survey (SMD: 0.71, 95% CIs: 0.30 to 1.12; SMD: 0.81, 95% CIs: 0.40 to 1.23, respectively). Exercise training improved exercise capacity, left ventricular ejection fraction, and some the 36-item Short Form Health Status Survey scores, and reduced BMI in AF patients.

Sex differences in health status and rehabilitation outcomes in patients with atrial fibrillation treated with ablation: Results from the CopenHeartRFA trial

Background:

Increased physical capacity after comprehensive rehabilitation in patients with atrial fibrillation (AF) undergoing ablation has been found in the CopenHeartRFA trial. The purpose of this study was to investigate: (a) sex differences in health status, psychological distress and quality of life, (b) sex differences in rehabilitation outcomes and (c) predictors of effect of rehabilitation.

Methods:

We conducted an exploratory analysis of data from the randomized CopenHeartRFA trial, where patients treated with ablation were randomized with 1:1 to comprehensive rehabilitation consisting of a physical exercise program and psycho-educational consultations versus usual care. Sex disparities in health status were tested using Chi-square and t-tests.

Results:

Included were: 151 men (median age 59.25 years) and 59 women (median age 62.5 years). At hospital discharge, women reported lower physical health status compared with men. Among women, significant differences were found in the 6-min walk test [rehabilitation: 496.8 meters (SD 98.5) versus 559.3meters (SD 55.5) and usual care: 521.9 meters (SD 97.8) versus 530.9 meters (SD 102.2), p = 0.01] and exercise time [rehabilitation: 387.6 s (SD 126.0) versus 463.2 s (SD 121.8) and usual care: 353.4 s (SD 145.2) versus 355.8 s (SD 154.8), p < 0.004] and among men in the sit-to-stand test. Significant differences were found in mental health outcomes among men and in quality of life scores among women. Patients with a European Heart Rhythm Association (EHRA) score I-II had a positive effect of rehabilitation.

Conclusion:

The results suggest that sex differences exist in self-reported health after rehabilitation in patients ablated for AF. Patients with an I–II EHRA score seem more likely to gain from the rehabilitation programme compared with those with a III–IV score.

Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry

AIMS

Physical activity is protective against cardiovascular (CV) events, both in general population and in high-risk CV cohorts. However, the relationship between physical activity with major adverse outcomes in atrial fibrillation (AF) is not well-established. Our aim was to analyse this relationship in a 'real-world' AF population. Second, we investigated the influence of physical activity on arrhythmia progression.

METHODS AND RESULTS

We studied all patients enrolled in the EURObservational Research Programme on AF (EORP-AF) Pilot Survey. Physical activity was defined as 'none', 'occasional', 'regular', and 'intense', based on patient self-reporting. Data on physical activity were available for 2442 patients: 38.9% reported none, 34.7% occasional, 21.7% regular, and 4.7% intense physical activity. Prevalence of the principal CV risk factors progressively decreased from none to intense physical activity. Lower rates of CV death, all-cause death, and composite outcomes were found in AF patients who reported regular and intense physical activity (P < 0.0001). Increasing physical activity was inversely associated with CV death/any thromboembolic event (TE)/bleeding in the whole cohort, irrespective of gender, paroxysmal AF, elderly age, or high stroke risk. Any level of physical activity intensity was significantly associated with lower risk of CV death/any TE/bleeding at 1-year follow-up. Physical activity was not significantly associated with arrhythmia progression.

CONCLUSION

Atrial fibrillation patients taking regular exercise were associated with a lower risk of all-cause death, even when we considered various subgroups, including gender, elderly age, symptomatic status, and stroke risk class. Efforts to increase physical activity among AF patients may improve outcomes in these patients.

Cardiovascular exercise and burden of arrhythmia in patients with atrial fibrillation - A randomized controlled trial

Background

Physical activity at moderate-high intensity is recommended to prevent lifestyle diseases. Patients with atrial fibrillation are at risk of a sedentary lifestyle due to fear of exercise-induced episodes of atrial fibrillation. The burden of arrhythmia can be reduced by physical exercise. The effect of exercise intensity on burden of atrial fibrillation needs to be studied further.

Methods and results

In a 12-week randomized controlled trial, 76 patients with paroxysmal/persistent atrial fibrillation were allocated to perform exercise at either low intensity or high intensity (50% and 80% of maximal perceived exertion, respectively). Primary outcome was burden of AF measured by daily electrocardiography-reporting during 12 weeks. Secondarily, change in maximal oxygen uptake (peak VO₂) and 1-year hospitalization was compared between low and high intensity exercise. Sixty-three patients completed the follow-up. In the intention-to-treat analysis, we found no statistical difference in burden of atrial fibrillation between low and high intensity exercise (incidence rate ratio 0.742, 95% CI 0.29–1.91, P = 0.538). No serious adverse events were reported and there was no difference in hospitalization between the two exercise groups. Both exercise groups improved significantly in peak VO₂ (low intensity: 3.62 mL O₂/kg/min, SD 3.77; high intensity: 2.87 mL O₂/kg/min, SD 4.98), with no statistical difference between-groups (mean difference: 0.76 mL O₂/kg/min, 95% CI -3.22–1.7).

Conclusions

High intensity physical exercise was not superior to low intensity physical exercise in reducing burden of atrial fibrillation. HI exercise was well tolerated; no evidence of an increased risk was found for HI compared to LI exercise. Larger studies are required to further prove our findings.

Trial registration

ClinicalTrials.gov NCT01817998

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Exercise-based cardiac rehabilitation may benefit adults with atrial fibrillation or those who had been treated for atrial fibrillation. Atrial fibrillation is caused by multiple micro re-entry circuits within the atrial tissue, which result in chaotic rapid activity in the atria.

OBJECTIVES

To assess the benefits and harms of exercise-based rehabilitation programmes, alone or with another intervention, compared with no-exercise training controls in adults who currently have AF, or have been treated for AF.

SEARCH METHODS

We searched the following electronic databases; CENTRAL and the Database of Abstracts of Reviews of Effectiveness (DARE) in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS Bireme, and three clinical trial registers on 14 July 2016. We also checked the bibliographies of relevant systematic reviews identified by the searches. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that investigated exercise-based interventions compared with any type of no-exercise control. We included trials that included adults aged 18 years or older with atrial fibrillation, or post-treatment for atrial fibrillation.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We assessed the risk of bias using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots, and by using standard Chi² and I² statistics. We performed meta-analyses using fixed-effect and random-effects models; we used standardised mean differences where different scales were used for the same outcome. We assessed the risk of random errors with trial sequential analysis (TSA) and used the GRADE methodology to rate the quality of evidence, reporting it in the 'Summary of findings' table.

MAIN RESULTS

We included six RCTs with a total of 421 patients with various types of atrial fibrillation. All trials were conducted between 2006 and 2016, and had short follow-up (eight weeks to six months). Risks of bias ranged from high risk to low risk.The exercise-based programmes in four trials consisted of both aerobic exercise and resistance training, in one trial consisted of Qi-gong (slow and graceful movements), and in another trial, consisted of inspiratory muscle training.For mortality, very low-quality evidence from six trials suggested no clear difference in deaths between the exercise and no-exercise groups (relative risk (RR) 1.00, 95% confidence interval (CI) 0.06 to 15.78; participants = 421; I² = 0%; deaths = 2). Very low-quality evidence from five trials suggested no clear difference between groups for serious adverse events (RR 1.01, 95% CI 0.98 to 1.05; participants = 381; I² = 0%; events = 8). Low-quality evidence from two trials suggested no clear difference in health-related quality of life for the Short Form-36 (SF-36) physical component summary measure (mean difference (MD) 1.96, 95% CI -2.50 to 6.42; participants = 224; I² = 69%), or the SF-36 mental component summary measure (MD 1.99, 95% CI -0.48 to 4.46; participants = 224; I² = 0%). Exercise capacity was assessed by cumulated work, or maximal power (Watt), obtained by cycle ergometer, or by six minute walking test, or ergospirometry testing measuring VO2 peak. We found moderate-quality evidence from two studies that exercise-based rehabilitation increased exercise capacity, measured by VO2 peak, more than no exercise (MD 3.76, 95% CI 1.37 to 6.15; participants = 208; I² = 0%); and very low-quality evidence from four studies that exercise-based rehabilitation increased exercise capacity more than no exercise, measured by the six-minute walking test (MD 75.76, 95% CI 14.00 to 137.53; participants = 272; I² = 85%). When we combined the different assessment tools for exercise capacity, we found very low-quality evidence from six trials that exercise-based rehabilitation increased exercise capacity more than no exercise (standardised mean difference (SMD) 0.86, 95% CI 0.46 to 1.26; participants = 359; I² = 65%). Overall, the quality of the evidence for the outcomes ranged from moderate to very-low.

AUTHORS' CONCLUSIONS

Due to few randomised patients and outcomes, we could not evaluate the real impact of exercise-based cardiac rehabilitation on mortality or serious adverse events. The evidence showed no clinically relevant effect on health-related quality of life. Pooled data showed a positive effect on the surrogate outcome of physical exercise capacity, but due to the low number of patients and the moderate to very low-quality of the underpinning evidence, we could not be certain of the magnitude of the effect. Future high-quality randomised trials are needed to assess the benefits and harms of exercise-based cardiac rehabilitation for adults with atrial fibrillation on patient-relevant outcomes.

Cardiac rehabilitation versus usual care for patients treated with catheter ablation for atrial fibrillation: Results of the randomized CopenHeartRFA trial

BACKGROUND

To assess the effects of comprehensive cardiac rehabilitation compared with usual care on physical activity and mental health for patients treated with catheter ablation for atrial fibrillation.

METHODS

The patients were randomized 1:1 stratified by paroxysmal or persistent atrial fibrillation and sex to cardiac rehabilitation consisting of 12 weeks physical exercise and four psycho-educational consultations plus usual care (cardiac rehabilitation group) versus usual care. The primary outcome was Vo₂ peak. The secondary outcome was self-rated mental health measured by the Short Form-36 questionnaire. Exploratory outcomes were collected.

RESULTS

210 patients were included (mean age: 59 years, 74% men), 72% had paroxysmal atrial fibrillation prior to ablation. Compared with usual care, the cardiac rehabilitation group had a beneficial effect on Vo₂ peak at four months (24.3mL kg^-1 min^-1 versus 20.7mL kg^-1 min^-1, p of main effect=0.003, p of interaction between time and intervention=0.020). No significant difference between groups on Short Form-36 was found (53.8 versus 51.9 points, P=.20). Two serious adverse events (atrial fibrillation in relation to physical exercise and death unrelated to rehabilitation) occurred in the cardiac rehabilitation group versus one in the usual care group (death unrelated to intervention) (P=.56). In the cardiac rehabilitation group 16 patients versus 7 in the usual care group reported non-serious adverse events (P=.047).

CONCLUSION

Comprehensive cardiac rehabilitation had a positive effect on physical capacity compared with usual care, but not on mental health. Cardiac rehabilitation caused more non-serious adverse events.

Effects of inspiratory muscle training on pulmonary function, respiratory muscle strength and functional capacity in patients with atrial fibrillation: a randomized controlled trial

Objective:

To investigate the effects of inspiratory muscle training on pulmonary function, respiratory muscle strength and functional capacity in patients with atrial fibrillation.

Design:

Prospective randomized controlled single-blind study.

Setting:

Cardiology department of a university hospital.

Subjects:

A total of 38 patients with permanent atrial fibrillation were randomly allocated to either a treatment group ( n = 19; age 66.2 years (8.8)) or a control group ( n = 19; age 67.1 years (6.4)).

Methods:

The training group received inspiratory muscle training at 30% of maximal inspiratory pressure for 15 minutes twice a day, 7 days a week, for 12 weeks alongside the standard medical treatment. The control group received standard medical treatment only. Spirometry, maximal inspiratory and expiratory pressures and 6-minute walking distance was measured at the beginning and end of the study.

Results:

There was a significant increase in maximal inspiratory pressure (27.94 cmH2O (8.90)), maximal expiratory pressure (24.53 cmH2O (10.34)), forced vital capacity (10.29% (8.18) predicted), forced expiratory volume in one second (13.88% (13.42) predicted), forced expiratory flow 25%–75% (14.82% (12.44) predicted), peak expiratory flow (19.82% (15.62) predicted) and 6-minute walking distance (55.53 m (14.13)) in the training group ( p < 0.01). No significant changes occurred in the control group ( p > 0.05).

Conclusion:

Inspiratory muscle training can improve pulmonary function, respiratory muscle strength and functional capacity in patients with atrial fibrillation.

High-intensity interval training improves cardiovascular health, exercise capacity, and quality of life in permanent atrial fibrillation: a case study

Persons with permanent atrial fibrillation experience reduced exercise tolerance, weight gain, and an associated decline in overall health. We report on a 74-year-old man with permanent atrial fibrillation who underwent a 10-week high-intensity interval training program. Substantial improvements in heart rate, blood pressure, aerobic and functional capacity, and quality of life were observed. These are desirable as these patients are not candidates for other treatment options and more effective therapies for the treatment of atrial fibrillation are needed.

[Atrial fibrillation and physical activity. An overview]

A training-induced increase in vagal tone, left atrial enlargement and high atrial volume load due to exercise can theoretically favor induction and continuation of atrial fibrillation (AF) in (endurance) athletes. However, there is currently no evidence for a higher occurrence of AF in young endurance athletes in comparison to an age-matched normal population. The correlate of long-term endurance training results in proarrhythmogenic atrial remodeling in a rat model. The results of some studies also suggest that there may be atrial remodeling in humans, which might be an explanation for the comparatively higher incidence of AF in veteran athletes, whereby the relative risk might have been overestimated due to methodological problems, e.g. due to insufficient consideration of "new" AF risk factors. To date, there are no indications for an increased risk of AF due to normal physical activity: on the contrary, moderate physical activity seems to decrease the risk for AF. For an individual evaluation of sports participation of patients with AF, the overall cardiac situation, atrioventricular conduction during exercise, a possible oral anticoagulation as well as the sport and training intensity practiced are important. Well-adapted training for patients with AF has to be considered as safe and effective in terms of the overall positive effects of physical activity in patients with cardiovascular problems, for example due to a positive influence on cardiovascular risk factors.

Role of the autonomic nervous system in atrial fibrillation: pathophysiology and therapy

Autonomic nervous system activation can induce significant and heterogeneous changes of atrial electrophysiology and induce atrial tachyarrhythmias, including atrial tachycardia and atrial fibrillation (AF). The importance of the autonomic nervous system in atrial arrhythmogenesis is also supported by circadian variation in the incidence of symptomatic AF in humans. Methods that reduce autonomic innervation or outflow have been shown to reduce the incidence of spontaneous or induced atrial arrhythmias, suggesting that neuromodulation may be helpful in controlling AF. In this review, we focus on the relationship between the autonomic nervous system and the pathophysiology of AF and the potential benefit and limitations of neuromodulation in the management of this arrhythmia. We conclude that autonomic nerve activity plays an important role in the initiation and maintenance of AF, and modulating autonomic nerve function may contribute to AF control. Potential therapeutic applications include ganglionated plexus ablation, renal sympathetic denervation, cervical vagal nerve stimulation, baroreflex stimulation, cutaneous stimulation, novel drug approaches, and biological therapies. Although the role of the autonomic nervous system has long been recognized, new science and new technologies promise exciting prospects for the future.