Atrial fibrillation and cardiac rehabilitation: an overview

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, disrupts the heart's rhythm through numerous small re-entry circuits in the atrial tissue, leading to irregular atrial contractions. The condition poses significant health risks, including increased stroke risk, heart failure, and reduced quality of life. Given the complexity of AF and its growing incidence globally, exercise-based cardiac rehabilitation (ExCR) may provide additional benefits for people with AF or those undergoing routine treatment for the condition.

OBJECTIVES

To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF.

SEARCH METHODS

We searched the following electronic databases: CENTRAL in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS BIREME, and two clinical trial registers on 24 March 2024. We imposed no language restrictions.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF.

DATA COLLECTION AND ANALYSIS

Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as 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 random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO2peak) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to aerobic plus resistance programmes. Using univariate meta-regression, there was evidence of significant association between location of trial and length of longest follow-up on exercise capacity.

AUTHORS' CONCLUSIONS

Due to few randomised participants and typically short-term follow-up, the impact of ExCR on all-cause mortality or serious adverse events for people with AF is uncertain. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO2peak. Future high-quality RCTs are needed to assess the benefits of ExCR for people with AF on patient-relevant outcomes including AF symptom severity and burden, AF recurrence, AF-specific quality of life, and clinical events such as mortality, readmissions, and serious adverse events. High-quality trials are needed to investigate how AF subtype and clinical setting (i.e. primary and secondary care) may influence ExCR effectiveness.

[Rehabilitation for atrial fibrillation : Impact on arrhythmia and cumulative risk factors]

BACKGROUND

Atrial fibrillation (AF) occurs in cardiovascular diseases but also in hyperthyroidism. The independent risk factors (RF) that are cumulatively the cause of AF include arterial hypertension, obesity, malnutrition, alcohol and tobacco consumption, lack of exercise, diabetes mellitus, and sleep-related breathing disorders. These cause and reinforce each other and are amplified by psychosocial RF. This also leads to morphological consequences such as atrial cardiomyopathy or diastolic heart failure (HFpEF). Therapy focuses on stroke prophylaxis through anticoagulation and rhythm or frequency control of the AF.

AIM

The risk factors of AF are presented here in detail. RF control must be included in the management of AF. Effective risk management should definitely include the patient's lifestyle.

RESULTS AND CONCLUSION

Although RF management can be integrated into the acute medical and outpatient treatment of AF, there is little scope to deal with the individual risk profile of individual patients. With the bio-psycho-social treatment approach, cardiological rehabilitation offers the opportunity to establish individual, lifestyle-oriented risk management and to achieve symptomatic improvement, decreased AF burden, better performance, and a better quality of life through correctly dosed training. Further studies to clarify the question of whether clinical endpoints such as hospitalization or morbidity and mortality are reduced by cardiac rehabilitation in AF are desirable.

[The importance of cardiorehabilitation in the era of modern treatment of cardio-vascular diseases]

Cardiac rehabilitation (CR) has a class IA indication in international and national guidelines as an intervention with proven efficacy for decreasing cardiovascular and all-cause mortality in various categories of cardiological patients. However, CR is one of the least used current technologies for the treatment of patients with cardiovascular diseases worldwide. This article presents the state of the CR problem during the epoch of high-tech treatments of cardiovascular diseases; the prevalence of using CR in various countries; traditional and new methodological approaches, including telemedicine; and clinical and prognostic effects of CR in various categories of patients with cardiovascular diseases.

Relationship Between Preoperative Anxiety and Atrial Fibrillation After Coronary Artery Bypass Graft Surgery

BACKGROUND

Atrial fibrillation is a form of arrhythmia that frequently occurs after coronary artery bypass graft surgery. Psychological factors may be involved in the development of atrial fibrillation, although the specific effect of anxiety remains unclear.

PURPOSE

This study was designed to evaluate the relationship between preoperative anxiety levels and atrial fibrillation after coronary artery bypass graft surgery.

METHODS

This descriptive design study recruited a sample of 126 patients. The data were collected by the researcher using a patient information form and the State-Trait Anxiety Scale.

RESULTS

Atrial fibrillation developed in 26.5% of the sample. Those who developed atrial fibrillation had a mean trait anxiety scale score of 40.2 ± 7.8, which is statistically significant. According to the results of logistic regression, it was observed that increased trait anxiety score, increased age, presence of comorbid disease, and noncompliance with respiratory physiotherapy increased the risk of developing atrial fibrillation.

CONCLUSION/IMPLICATIONS FOR PRACTICE

Preoperative anxiety levels were shown to be a significant factor promoting the development of atrial fibrillation after coronary artery bypass graft surgery. The results support measuring anxiety levels in patients as a standard procedure before performing this surgical procedure.

Fear of Recurrence of Atrial Fibrillation: Translating a Cancer Fear Model to the Atrial Fibrillation Patient Experience

BACKGROUND

Atrial fibrillation occurs when rapid and disorganized electrical signals cause the atria in the heart to beat irregularly and is associated with an increased risk for stroke. Despite medical advancements, first and second line atrial fibrillation treatments exhibit significant recurrence rates. Because of this, atrial fibrillation patients often experience disease-specific fears that are not routinely assessed and targeted in clinical management. Fear of recurrence models in cancer research and other cardiac-specific fears have paved the way for a patient-centric approach to disease intervention.

PURPOSE

Clinical assessment focused solely on the taxonomy of anxiety disorders may miss key components unique to the atrial fibrillation patient experience. An anxiety disorder diagnosis in the presence of an arrhythmia could be misleading and ultimately fail to address patient needs. Modeled from the cancer literature, providers may benefit from a broader disease specific conceptualization for AF patients that differs from a general DSM-5 diagnosis.

AIMS

The objectives of this paper are: (1) to review the medical aspects of atrial fibrillation, (2) to examine the comparability of fear of recurrence concept from cancer literature to the atrial fibrillation patient, and (3) to suggest considerations of these novel concepts in patient care.

FUTURE DIRECTIONS

Increased understanding of fear of recurrence among atrial fibrillation patients aims to define and assess fear of recurrence components, determine treatment targets, and ultimately improve patient outcomes.

Cardiac rehabilitation in heart failure: Indications for exercise training based on heart failure phenotype

Exercise intolerance with dyspnea and fatigue is pervasive amongst individuals with heart failure (HF) due to both central and peripheral mechanisms. Cardiac rehabilitation (CR) is a cornerstone therapy for numerous cardiovascular disease (CVD) processes, and it's use in HF with reduced ejection fraction (HFrEF) has shown significant benefit in improved mortality and quality of life (QoL). Less is known about the benefit of CR in the setting of HF with preserved ejection fraction (HFpEF), and optimal exercise therapy (ET) may vary based on underlying disease phenotype. Here we offer review of existing data for ET in both HFrEF and HFpEF with proposed exercise treatment modalities based on underlying comorbidities and variable phenotypes.

Cardiac rehabilitation and its essential role in the secondary prevention of cardiovascular diseases

Cardiovascular diseases are the most common causes of mortality worldwide. They are frequently the reasons for patient hospitalization, their incapability for work, and disability. These diseases represent a significant socio-economic burden affecting the medical system as well as patients and their families. It has been demonstrated that the etiopathogenesis of cardiovascular diseases is significantly affected by lifestyle, and so modification of the latter is an essential component of both primary and secondary prevention. Cardiac rehabilitation (CR) represents an efficient secondary prevention model that is especially based on the positive effect of regular physical activity. This review presents an overview of basic information on CR with a focus on current trends, such as the issue of the various training modalities, utilization, and barriers to it or the use of telemedicine technologies. Appropriate attention should be devoted to these domains, as CR continues evolving as an effective and readily available intervention in the future.

The Beneficial Effects of Cardiac Rehabilitation

Cardiac rehabilitation (CR) is a combined range of measures aimed at providing patients with cardiovascular disease with the optimum psychological and physical conditions so that they themselves can prevent their disease from progressing or potentially reversing its course. The following measures are the three main parts of CR: exercise training, lifestyle modification, and psychological intervention. The course of cardiac rehabilitation generally takes 3-4 weeks.