Effectiveness of additional resistance and balance training and telephone support program in exercise-based cardiac rehabilitation on quality of life and physical activity: Randomized control trial

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.

Sex Differences in Changes in Cardiorespiratory Fitness and Additional Health Outcomes Following Exercise Training in Adults With Atrial Fibrillation: A Systematic Review and Meta-Analysis

PURPOSE

Improving cardiorespiratory fitness (CRF) through exercise training is associated with lower morbidity and mortality in patients with atrial fibrillation (AF). Smaller CRF improvements have been suggested in females than males with cardiovascular disease following exercise training. This systematic review compared changes in CRF (primary) and additional physical and mental health outcomes following exercise training between females and males with AF.

REVIEW METHODS

Five bibliographic databases were searched to identify prospective studies implementing exercise training in patients with AF. The mean difference (MD) in the change following exercise training was compared between sexes using random-effects meta-analyses.

SUMMARY

Sex-specific data were obtained from 19 of 63 eligible studies, with 886 participants enrolled in exercise training (n = 259 [29%] females; female: 68 ± 7 years, male: 66 ± 8 years). Exercise training was 6 weeks to 1 year in duration and mostly combined moderate- to vigorous-intensity aerobic and resistance training, 2 to 6 d/wk. Changes in CRF did not differ between sexes (MD = 0.15: 95% CI, -1.08 to 1.38 mL O2/kg/min; P = .81; I2 = 27%). Severity of AF (MD = 1.00: 95% CI, 0.13-1.87 points; I2 = 0%), general health perceptions (MD = -3.71: 95% CI, -6.88 to -0.55 points; I2 = 22%), and systolic blood pressure (MD = 3.11: 95% CI, 0.14-6.09 mmHg; I2 = 42%) improved less in females than in males. Females may benefit from more targeted exercise training programs given their smaller improvement in several health outcomes than males. However, our findings are largely hypothesis-generating, considering the limited sample size and underrepresentation of females (29% females in our review vs 47% females with AF globally).

Resistance Training in Patients With Coronary Artery Disease, Heart Failure, and Valvular Heart Disease: A REVIEW WITH SPECIAL EMPHASIS ON OLD AGE, FRAILTY, AND PHYSICAL LIMITATIONS

PURPOSE

Current guidelines recommend individually adapted resistance training (RT) as a part of the exercise regime in patients with cardiovascular diseases. The aim of this review was to provide insights into current knowledge and understanding of how useful, feasible, safe, and effective RT is in patients with coronary artery disease (CAD), heart failure (HF), and valvular heart disease (VHD), with particular emphasis on the role of RT in elderly and/or frail patients.

REVIEW METHODS

A review based on an intensive literature search: systematic reviews and meta-analyses published in 2010 or later; recent studies not integrated into meta-analyses or systematic reviews; additional manual searches.

SUMMARY

The results highlight the evaluation of effects and safety of RT in patients with CAD and HF with reduced ejection fraction (HFrEF) in numerous meta-analyses. In contrast, few studies have focused on RT in patients with HF with preserved ejection fraction (HFpEF) or VHD. Furthermore, few studies have addressed the feasibility and impact of RT in elderly cardiac patients, and data on the efficacy and safety of RT in frail elderly patients are limited. The review results underscore the high prevalence of age-related sarcopenia, disease-related skeletal muscle deconditioning, physical limitations, and frailty in older patients with cardiovascular diseases (CVD). They underline the need for individually tailored exercise concepts, including RT, aimed at improving functional status, mobility, physical performance and muscle strength in older patients. Furthermore, the importance of the use of assessment tools to diagnose frailty, mobility/functional capacity, and physical performance in the elderly admitted to cardiac rehabilitation is emphasized.