MediYoga as a part of a self-management programme among patients with paroxysmal atrial fibrillation - a randomised study

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.

Assessing the impact of atrial fibrillation self-care interventions: A systematic review

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

MediYoga compared to physiotherapy treatment as usual for patients with stress-related symptoms in primary care rehabilitation: A randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the effect of MediYoga as a group treatment to conventional treatment provided by a physiotherapist for people with perceived stress-related symptoms.

DESIGN

Randomized controlled trial.

SETTINGS

Primary care rehabilitation, Gothenburg Sweden.

SUBJECTS

Fifty-five patients with stress-related symptoms were invited to participate. Nine patients declined, and a total of 46 patients aged 26-70 years (mean 47), 44 women and two men were randomized, 23 to the MediYoga group and 23 to the physiotherapy treatment as usual group.

INTERVENTIONS

The MediYoga group performed MediYoga for one hour a week during an 8-week period. The control group received physiotherapy treatment as usual.

MAIN MEASURES

Data were mainly collected by self-reported questionnaires. For primary outcome the Swedish version of the Perceived Stress Scale (PSS) was used. Secondary outcomes were the Hospital Anxiety and Depression Scale (HADS), EuroQol-5D (EQ-5D) and EuroQol-Visual Analog Scale (EQ-VAS). Thoracic excursion was the only physical measurement. Mixed effect model was used for analyse.

RESULTS

For the primary outcome PSS, there was a close to statistically significant group effect over time advantaging MediYoga over physiotherapy (P = 0.06). For secondary outcomes, the group effect over time was statistically significant in HADS anxiety (P = 0.01) and EQ-VAS (P = 0.03). There was a group trend over time advantaging MediYoga in HADS depression (P = 0.08).

CONCLUSION

Despite a large dropout in both groups, MediYoga can be recommended as a treatment option for people suffering from stress-related symptoms.

TRIAL REGISTRATION

Registered in: ClinicalTrials.gov NCT02907138.

Gender differences in health-related quality of life, blood pressure and heart rate among patients with paroxysmal atrial fibrillation after performing MediYoga

Introduction

Patients with paroxysmal atrial fibrillation experience low health-related quality of life which can be improved by performing yoga. The aim of this study was to evaluate gender differences in health-related quality of life, blood pressure and heart rate among patients with paroxysmal atrial fibrillation after performing MediYoga.

Methods

This is a secondary analysis of subgroups, investigating the yoga groups, from two randomized controlled trials (RCT 1: yoga group versus control group, RCT 2: a three-armed randomized study with yoga, control and relaxation groups). The yoga groups performed MediYoga for one hour/week over a 12-week period in both studies. Quality of life (SF-36), blood pressure and heart rate were collected at baseline and end of study.

Results

No differences were found between the women and men. Within the women's group, there were improvements in vitality (p = 0.011), social function (p = 0.022), mental health (p = 0.007) and Mental Components Summary (p = 0.022). There were differences within the men's group in bodily pain (p = 0.005), general health (p = 0.003), vitality (p = 0.026), social function (p = 0.005), role-emotion (p = 0.011) and Mental Components Summary (p = 0.018). Within the women's group, differences were observed in systolic blood pressure (p = 0.010) and diastolic blood pressure (p = <0.001). The men's group also showed improvement in diastolic blood pressure (p = 0.021).

Conclusion

MediYoga improved mental health as well as diastolic blood pressure in both men and women with PAF. This study suggests that both men and women, with PAF, may benefit from complementary treatment such as yoga.Clinical Trial Gov Id: NCT01789372.

[Alternative treatment strategies for atrial fibrillation : Benefits from yoga?]

Atrial fibrillation, the most common sustained cardiac arrhythmia, is associated with significant morbidity, mortality, and healthcare utilization. Since the procedures used to treat atrial fibrillation have a number of limitations and risks, there is a growing interest in alternative treatment strategies for patients with atrial fibrillation. One such option is yoga. To date, only a few studies are available on its effect on atrial fibrillation. However, these suggest that yoga may indeed be able to reduce the frequency of the arrhythmia and its progression. The risk factors for atrial fibrillation and quality of life in affected patients are also positively affected. As adverse effects and complications are extremely rare with competent guidance, yoga may already be recommended now. However, further clinical studies are needed to provide recommendations that meet evidence-based criteria.

Effects of different exercise types on quality of life for patients with atrial fibrillation: a systematic review and meta-analysis

AIM

To investigate the effectiveness of exercise and the most effective types of exercise for patients with atrial fibrillation (AF) to improve health-related quality of life (HRQoL) and exercise capacity, and reduce AF burden, AF recurrence and adverse events.

METHODS AND RESULTS

Systematic search in PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL Plus, and SPORTDiscus for randomized controlled trials (RCTs) and nonrandomized pre-post intervention studies investigating the effect of different types of exercise on AF patients. After exclusion, 12 studies (11 RCTs, 1 prepost) with a total of 670 participants were included. Exercise interventions consisted of aerobic exercise, aerobic interval training (AIT), Qigong, yoga, and exercise-based cardiac rehabilitation (CR). There were significant positive effects of exercise on general health {mean difference [MD] = 6.42 [95% confidence interval (CI): 2.90, 9.93]; P = 0.0003; I2 = 17%} and vitality [MD = 6.18 (95% CI: 1.94, 10.41); P = 0.004; I2 = 19%)] sub-scales of the Short Form 36-item questionnaire (SF-36). Qigong resulted in a significant improvement in the 6-min walk test [MD = 105.00m (95% CI: 19.53, 190.47)]. Exercise-based CR and AIT were associated with a significant increment in V̇O2peak, and AIT significantly reduced AF burden. Adverse events were few and one intervention-related serious adverse event was reported for exercise-based CR.

CONCLUSION

Exercise led to improvements in HRQoL, exercise capacity, and reduced AF burden. The available exercise interventions for AF patients are few and heterogeneous. Future studies are needed for all types of exercise intervention in this patient group to (co-)develop an optimized exercise training intervention for AF patients.

Atrial Fibrillation Specific Exercise Rehabilitation: Are We There Yet?

Regular physical activity and exercise training are integral for the secondary prevention of cardiovascular disease. Despite recent advances in more holistic care pathways for people with atrial fibrillation (AF), exercise rehabilitation is not provided as part of routine care. The most recent European Society of Cardiology report for AF management states that patients should be encouraged to undertake moderate-intensity exercise and remain physically active to prevent AF incidence or recurrence. The aim of this review was to collate data from primary trials identified in three systematic reviews and recent real-world cohort studies to propose an AF-specific exercise rehabilitation guideline. Collating data from 21 studies, we propose that 360–720 metabolic equivalent (MET)-minutes/week, corresponding to ~60–120 min of exercise per week at moderate-to-vigorous intensity, could be an evidence-based recommendation for patients with AF to improve AF-specific outcomes, quality of life, and possibly prevent long-term major adverse cardiovascular events. Furthermore, non-traditional, low-moderate intensity exercise, such as Yoga, seems to have promising benefits on patient quality of life and possibly physical capacity and should, therefore, be considered in a personalised rehabilitation programme. Finally, we discuss the interesting concepts of short-term exercise-induced cardioprotection and ‘none-response’ to exercise training with reference to AF rehabilitation.

Mind and body interventions in cardiology : The importance of the brain-heart connection

Mind and body interventions aim to harness the "relaxation response", reduce stress, and improve quality of life, which is important in the search for more holistic treatment approaches in cardiovascular medicine. This article describes the pertinent pathophysiological correlates building the mechanistic backbone for these interventions. They can be found in the complex connections of brain and heart (central and autonomic nervous system, hypothalamic-pituitary-adrenal axis), which play an important role in the development of various cardiovascular disease conditions and hold potential as therapeutic targets. The evidence regarding the effect of mind and body interventions in cardiology with a focus on arrhythmia and psychocardiology is reviewed systematically. To date, mostly small pilot studies prone to substantial bias and without adequate power have dominated the field and longer-term outcome data are lacking. Ultimately, integration of mind and body interventions could empower patients by strengthening their individual responsibility and mental power in addition to the benefits of stress reduction and improvement of quality of life. Whether this will translate into relevant longer-term clinical outcomes remains uncertain. Therefore, this field offers multifaceted opportunities for further research and practical applications.

Association of Music Interventions With Health-Related Quality of Life: A Systematic Review and Meta-analysis

IMPORTANCE

Increasing evidence supports the ability of music to broadly promote well-being and health-related quality of life (HRQOL). However, the magnitude of music's positive association with HRQOL is still unclear, particularly relative to established interventions, limiting inclusion of music interventions in health policy and care.

OBJECTIVE

To synthesize results of studies investigating outcomes of music interventions in terms of HRQOL, as assessed by the 36- and 12-Item Health Survey Short Forms (SF-36 and SF-12).

DATA SOURCES

MEDLINE, Embase, Web of Science, PsycINFO, ClinicalTrials.gov, and International Clinical Trials Registry Platform (searched July 30, 2021, with no restrictions).

STUDY SELECTION

Inclusion criteria were randomized and single-group studies of music interventions reporting SF-36 data at time points before and after the intervention. Observational studies were excluded. Studies were reviewed independently by 2 authors.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted and appraised using GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluations) by multiple authors. Inverse-variance random-effects meta-analyses quantified changes in SF-36 mental and physical component summary (respectively, MCS and PCS) scores from preintervention to postintervention and vs common control groups.

MAIN OUTCOMES AND MEASURES

SF-36 or SF-12 MCS and PCS scores, defined a priori.

RESULTS

Analyses included 779 participants from 26 studies (mean [SD] age, 60 [11] years). Music interventions (music listening, 10 studies; music therapy, 7 studies; singing, 8 studies; gospel music, 1 study) were associated with significant improvements in MCS scores (total mean difference, 2.95 points; 95% CI, 1.39-4.51 points; P < .001) and PCS scores (total mean difference, 1.09 points; 95% CI, 0.15-2.03 points; P = .02). In subgroup analysis (8 studies), the addition of music to standard treatment for a range of conditions was associated with significant improvements in MCS scores vs standard treatment alone (mean difference, 3.72 points; 95% CI, 0.40-7.05 points; P = .03). Effect sizes did not vary between music intervention types or doses; no evidence of small study or publication biases was present in any analysis. Mean difference in MCS scores met SF-36 minimum important difference thresholds (mean difference 3 or greater).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, music interventions were associated with clinically meaningful improvements in HRQOL; however, substantial individual variation in intervention outcomes precluded conclusions regarding optimal music interventions and doses for distinct clinical and public health scenarios.

Effects of Supervised Exercise Training on Atrial Fibrillation: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

PURPOSE

Atrial fibrillation (AF) is associated with the comorbidities of a sedentary lifestyle. Endurance athletes also show an increased incidence of AF. The role of exercise in the treatment of AF is unknown so this study aimed to examine the effects of supervised exercise on AF.

METHODS

A meta-analysis of randomized controlled trials (RCTs) examining supervised exercise training in participants with AF was performed. The primary outcome was AF recurrence and burden. Secondary outcomes included AF symptoms, quality of life, and cardiorespiratory fitness (CRF).

RESULTS

Thirteen RCTs, involving 1155 participants, were included. Paroxysmal AF was present in 34% and persistent AF in 64%. The types of exercise were diverse and included cardiac rehabilitation (64%), aerobic training (7%), Qi Gong (4%), interval training (11%), and yoga (15%). Exercise training reduced AF recurrence (relative risk = 0.77: 95% CI, 0.60-0.99), improved quality of life in 5 of the 10 components of the Short Form 36 survey, and improved CRF (standardized mean difference [SMD] = 0.56: 95% CI, 0.27-0.85). The AF burden was reduced only in studies that included continuous ambulatory monitoring (SMD =-0.49: 95% CI, -0.96 to -0.01) but not when all studies were included (SMD =-0.12: 95% CI, -0.61 to 0.38). There was no difference in adverse events between exercise and control.

CONCLUSIONS

Supervised exercise training is safe, reduces AF recurrence, and improves quality of life and CRF in participants with AF. Further large RCTs with ambulatory monitoring and robust exercise regimens are needed to assess the effects of exercise training on AF burden and AF symptoms.

Tele-Yoga in Long Term Illness-Protocol for a Randomised Controlled Trial Including a Process Evaluation and Results from a Pilot Study

BACKGROUND

For people with long-term illness, debilitated by severe symptoms, it can be difficult to attend regular yoga classes. We have therefore developed a tele-health format of yoga that can be delivered in the home. The tele-yoga was co-designed with members of a patient-organisation, yoga-instructor, and IT-technician. It includes live-streamed group-yoga sessions twice a week and an app with instructions on how to self-perform yoga.

AIM

To describe a study protocol for a randomised controlled trial (RCT) including a process evaluation and report on a pilot study evaluating method- and intervention-related components including feasibility, safety, and efficacy.

METHODS

Ten participants with heart failure aged between 41-76 years were randomised to tele-yoga (n = 5) or to the control group (n = 5). In the pilot study recruitment, enrolment, randomisation, and data collection of all outcomes including primary, secondary and process evaluation measures were tested according to the study protocol. Fidelity, adherence and acceptability to the tele-yoga group training and app use was determined. Safety was assessed by adverse events.

RESULTS

The pilot revealed that the methodological aspect of the protocol worked sufficiently in all aspects except for missing data in the physical test of two participants and one participant in the control-group that dropped out of the study at three months follow-up. The tele-yoga training did not lead to any adverse events or injuries, adherence of tele-yoga was sufficient according to preset limits. The tele-yoga intervention also showed some favourable trends of improvements in the composite-end point compared to the active control group. However, since data only was presented descriptively due to the small sample size, the impact of these trends should be interpreted carefully.

CONCLUSION

Our pilot study showed promising results in feasibility, safety, and acceptability of the tele-yoga intervention. Some changes in the protocol have been made to decrease the risk of missing data in the measures of physical function and in the full-scale RCT now ongoing the results of the sample size calculation for 300 participants have included the estimated level of drop outs and missing data.

The effect of slow breathing exercise on heart rate and blood pressure in patients undergoing percutaneous coronary intervention: a randomized controlled trial

AIM

To determine the effects of slow breathing exercise (SBE) on heart rate (HR) and blood pressure (BP) in patients after percutaneous coronary intervention (PCI).

METHODS AND RESULTS

The study is a single-blind, randomized controlled trial. Seventy-eight eligible patients after primary PCI were divided randomly into either the control group or the trial group. The control group only received routine post-PCI care. In addition to routine care, participants in the trial group performed SBE at home, two to three times for a total of 30 min every day for 12 weeks. The main outcomes were HR and BP measured in the office and at home. The secondary outcome was compliance with the breathing exercise. Patients allocated to the trial group, on average, performed 5.21 days/week for 26.00 min/day. The trial group showed a significant reduction in HR of 3.95 b.p.m. (P = 0.004) measured in the office. The reduction in HR measured in the office was greater for the trial group, with a significant difference between the two groups (P = 0.005). There was no significant difference between the two groups in HR measured at home. There was also no significant difference in BP measured in the office or at home between the two groups.

CONCLUSION

Slow breathing exercise is an effective non-pharmacological method to reduce HR in patients undergoing PCI. Further study is needed to confirm whether the intervention is effective on BP.

Optimization of atrial fibrillation care: management strategies and quality measures

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a leading cause of mortality and morbidity. Optimal management of AF is paramount to improve quality of life and reduce the impact on health and social care services. Owing to its strong associations with other cardiovascular and non-cardiovascular comorbidities, a holistic management approach to AF care is advocated but this is yet to be clearly defined by international clinical guidelines. This ambiguity has prompted us to review the available clinical evidence on different management strategies to optimize AF care in the context of performance and quality measures, which can be used to objectively assess standards of care.

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.