Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials

Lifestyle and risk factor modification in atrial fibrillation: a European Heart Rhythm Association survey

AIMS

Lifestyle and risk factor modification (LRFM) forms a central pillar in the management of atrial fibrillation (AF). This European Heart Rhythm Association (EHRA) survey aims to assess current clinical practice regarding LRFM across EHRA countries.

METHODS AND RESULTS

A 31-item questionnaire was developed and distributed amongst healthcare professionals via the EHRA and social media, between 23 September and 21 October 2024. Of 258 respondents from 28 countries, 39.9% reported that their healthcare system is badly or very badly designed to deliver meaningful LRFM. Risk factors that respondents felt least confident managing included psychological distress (42.2% of respondents not confident), sleep-disordered breathing (33.8%), and obesity (22.4%). Respondents estimated that 70% of patients with AF at their institution may benefit from exercise-based cardiac rehabilitation but that only 10% are referred for this. The most important barrier to cardiac rehabilitation in AF was identified as local programmes not accepting patients with AF only (42.1% of respondents). Despite 37.7% of respondents using a body mass index cut-off when deciding on catheter ablation suitability (with a mean cut-off of 36.7 ± 5.4 kg/m2), only 23.5% of patients with obesity are referred for formal dietary advice. Lack of patient motivation or engagement was identified as the most important barrier to weight loss (41.3% of respondents). Moreover, 89.6% of respondents routinely assess their patient's alcohol intake, whilst only 23.9% systemically assess for psychological distress and 16.5% for sleep-disordered breathing.

CONCLUSION

Delivering comprehensive LRFM in AF poses significant challenges. Improvements to healthcare infrastructures are required to successfully implement meaningful LRFM.

Exercise-based cardiac rehabilitation for patients with atrial fibrillation receiving catheter ablation: protocol for a feasibility randomised controlled trial (RCT) with embedded process evaluation

INTRODUCTION

Atrial fibrillation (AF) affects approximately 2.5% of the UK population, with a risk of 1 in 3-5 individuals after the age of 45 years. The global prevalence has risen sharply in the past two decades, from 33.3 million to 59 million individuals living with AF, and is associated with stroke, heart failure and mortality. Catheter ablation is commonly used for symptomatic patients to restore normal rhythm. A recent Cochrane review of randomised clinical trials (RCTs) has demonstrated that exercise training may induce positive effects on AF burden, AF severity, exercise capacity, and quality of life. The aim was therefore to investigate the feasibility of delivering exercise-based cardiac rehabilitation for patients with AF receiving catheter ablation within usual care in the UK.

METHODS AND ANALYSIS

A two-armed feasibility RCT with embedded process evaluation will be undertaken as a phased programme of work. Patients on a waiting list for catheter ablation will be offered a referral to cardiac rehabilitation. The intervention consists of supervised exercise sessions run by a clinical exercise physiologist and psychoeducation sessions. The trial (n=60) will involve one National Health Service (NHS) research site enrolling patients to assess intervention and study design processes. Primary outcomes are recruitment rate, adherence to exercise-based cardiac rehabilitation and loss to follow-up. Semistructured interviews and focus groups with patients and clinicians will be used to gather data on the acceptability of the intervention and study procedures. Secondary outcome measures will be taken at baseline (pre-intervention), post-intervention and at 6-month follow-up and will consist of AF burden, AF recurrence, quality of life, exercise capacity measured by peak oxygen consumption and echocardiographic parameters.

ETHICS AND DISSEMINATION

The trial was approved in the UK by the Northwest-Preston Research Ethics Committee (24/NW/0061; IRAS project ID: 330155). Results will be published in peer-reviewed journals and presented at national and international scientific meetings, and summaries will be communicated to participants.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT06401148.

High-intensity interval training to improve cardiorespiratory fitness in a patient with frailty and multimorbidity: A case report

BACKGROUND

Low cardiorespiratory fitness predicts worse postoperative outcomes, exacerbated by age and frailty. Preoperative High-Intensity Interval Training (HIIT) improves cardiorespiratory fitness and postoperative outcomes but is challenging to implement in frailty due to perceived risks.

PURPOSE

The aim of this case report was to demonstrate feasibility of HIIT in a patient with frailty and multimorbidity.

CASE PRESENTATION

An 83-year-old frail male with atrial fibrillation and limited mobility presenting with locally advanced rectal cancer was assessed as unfit for major surgery unless his cardiorespiratory fitness improved. Initial cardiopulmonary exercise testing demonstrated low cardiorespiratory fitness (peak oxygen consumption (V ˙ O2peak) of 11.45 mL·min-1·kg-1). He subsequently underwent 15 supervised HIIT sessions targeting a Rating of Perceived Exertion ≥ 15.

OUTCOMES

The patient demonstrated initial substantial improvements in his physical condition, increasing maximal work rate from 27.5 W to 55 W. However, there was no additional progress following session eight. At his post-exercise CPET he rapidly fatigued, resulting in a V ˙ O2peak of 7.4 mL·min-1kg-1. Clinical investigations revealed a worsening anemia with a hemoglobin of 92 g/L caused by an undiagnosed synchronous cecal tumor which was corrected preoperatively. Postoperatively, the patient recovered without complications and was successfully discharged home.

CONCLUSION

Personalized HIIT improved exercise duration and work rate and was associated with positive postoperative outcomes in this patient with frailty and multimorbidity. A unique feature of this case was the unexpected loss of training progress and V ˙ O2peak deterioration post-HIIT, which prompted further clinical investigations. These identified a worsening anemia and resulted in important changes in both the preoperative and intraoperative treatment.

The type of exercise most beneficial for quality of life in people with atrial fibrillation: a network meta-analysis

Introduction

Atrial fibrillation (AF) significantly detracts from health-related quality of life (HRQoL). Despite the promotion of exercise interventions for managing AF, the effectiveness of different exercise modalities remains to be clearly defined. This systematic review and network meta-analysis aims to evaluate the comparative effectiveness of various modes of exercise interventions on HRQoL in AF patients.

Methods

A random-effect network meta-analysis was performed. We conducted comprehensive searches across multiple databases, including PubMed, Web of Science, Embase, Cochrane Library, Scopus, and Chinese databases such as CNKI, WanFang Data, and VIP. The review included only randomized controlled trials (RCTs) that investigated the effects of exercise interventions on HRQoL among individuals diagnosed with AF.

Results

The network meta-analysis (NMA) incorporated 12 studies, of which five presented some concerns regarding risk of bias and one exhibited a high risk of bias. For total HRQoL in AF patients, aerobic exercise, and cardiac rehabilitation (CR) yielded standardised mean differences of 0.60 (95% CI: 0.02-1.13) and 0.59 (95% CI: 0.20-0.99), respectively. For the physical component of HRQoL, CR was most efficacious, demonstrating the highest Surface Under the Cumulative RAnking curve (SUCRA) value of 77%. For the mental component of HRQoL, high-intensity interval training (HIIT) was superior, with the highest SUCRA value of 90.7%.

Conclusions

Both aerobic exercise and CR effectively improve the physical and mental dimensions of HRQoL as well as overall HRQoL in patients with AF. However, for the mental component of HRQoL, HIIT was identified as the most effective intervention.

Impact of cardiac rehabilitation exercise frequency on exercise capacity in patients with coronary artery disease: a retrospective study

Cardiac rehabilitation (CR) significantly improves cardiovascular outcomes in patients with coronary artery disease (CAD). International guidelines vary in the minimum recommended frequency of supervised exercise from 1 to 3 sessions per week. This is the first study in the Middle East and North African regions assessing the impact of 2 versus 3 days/week of supervised exercise on peak exercise capacity in patients with CAD. Single-center retrospective cohort study involving 362 patients enrolled in the only CR center in the State of Qatar. Only high-quality data was included by strict evaluation of compliance to the exercise intervention. Fifty patients who underwent a symptom-limited exercise test before and after CR were included (31 patients on 2 days/week, 19 on 3 days/week). No significant differences were observed in baseline characteristics between groups. Exercise intervention differed significantly between groups in exercise training frequency (2 days/week: 1.97 ± 0.2 vs. 3 days/week: 2.7 ± 0.3; p < 0.00). Peak exercise capacity as peak metabolic equivalents of task (MET) significantly increased in both groups (2 days/week: Pre 8.3 ± 2.4 vs. Post 9.4 ± 2.9, p-value 0.00; 3 days/week: Pre 7.4 ± 1.6 vs. Post 8.4 ± 2.0, p-value 0.00). No significant difference was observed between groups for change in Peak Exercise Capacity (2 days/week 1.1 ± 1.1 vs. 3 days/week 1.0 ± 0.9, p = 0.87). When the total number of exercise sessions is equal, supervised exercise frequencies of 2 and 3 days/week may significantly and equally improve peak exercise capacity in patients with CAD.

A randomized controlled trial of a "Small Changes" behavioral weight loss treatment delivered in cardiac rehabilitation for patients with atrial fibrillation and obesity: study protocol for the BE-WEL in CR-AF study

BACKGROUND

Atrial fibrillation (AF) represents a global epidemic. Although international AF practice guidelines indicate weight loss for patients with AF and comorbid obesity (BMI ≥ 30 kg/m2) to alleviate symptom burden and improve prognosis, few cardiac rehabilitation (CR) programs include targeted weight loss treatment.

AIMS

This RCT protocol will evaluate the efficacy of a "Small Changes" behavioral weight loss treatment (BWLT) to produce clinically relevant (≥ 10%) weight loss among patients with AF and obesity undergoing CR, relative to CR alone. Secondary aims are to establish efficacy of CR + BWLT for improving AF symptoms, AF risk factors, and health-related quality of life.

METHODS

Adults (18 +) with AF and obesity will be recruited and randomized to receive CR + BWLT (intervention) or CR-only (control). Controls will receive CR consisting of supervised exercise and risk factor self-management for 12 weeks. The intervention group will receive CR plus BWLT (12 weekly, group-based virtual sessions, followed by 12 weeks of follow-up support). Weight and AF-risk factors will be assessed at pre-randomization, 12 weeks, 24 weeks, and 52 weeks. AF burden will be assessed using 30-s ECGs recorded bidaily and with AF symptoms. The primary endpoint of weight loss will be calculated from baseline to 52 weeks as a percentage of starting weight. Intention-to-treat analyses will compare the proportion in each group achieving ≥ 10% weight loss. Assuming success rates of 5% and 30% among controls and intervention groups, respectively, and a 30% loss to follow-up, 120 patients (60 per group) will provide 80% power to detect a difference using a two-sided independent test of proportions (alpha = 5%).

IMPACT

This clinical trial will be the first to demonstrate that adding BWLT to CR promotes clinically meaningful weight loss among patients with AF and comorbid obesity. Findings will inform design and execution of a large efficacy trial of long-term (e.g., 5-year) clinical endpoints (e.g., AF severity, mortality). Implementing weight control interventions designed to target the AF substrate in CR could dramatically reduce morbidity and enhance quality of life among patients living with AF in Canada.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT05600829. Registered October 31, 2022.

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.

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.

Cardiorespiratory fitness, atrial fibrillation and stroke: a review of the evidence in 2024

INTRODUCTION

The body of evidence linking cardiorespiratory fitness (CRF) levels with the risk of atrial fibrillation (AF) and stroke - two interconnected cardiovascular conditions - is not entirely consistent. Furthermore, specific CRF thresholds beyond which the risk of AF or stroke might not decrease are not well defined.

AREAS COVERED

This review summarizes research evidence on the role of CRF in the development of AF and stroke including dose-response relationships in general population participants, explores the biological mechanisms through which CRF may exert its effects, assesses the potential implications for clinical care and population health, identifies gaps in the current evidence, and suggest directions for future research. MEDLINE and Embase were searched from inception until July 2024 to identify observational longitudinal and interventional studies as well as systematic reviews and meta-analyses related to these study designs.

EXPERT OPINION

In the general population, increasing levels of CRF, achieved through consistent physical activity, can significantly reduce the likelihood of developing AF and stroke. The findings also advocate for a tailored approach to exercise prescriptions, acknowledging the plateau in benefits for AF risk beyond certain CRF levels, while advocating for higher intensity or prolonged activity to further reduce stroke risk.

A Systematic Review of the Completion of Cardiac Rehabilitation Programs for Adults Aged 18-50 Years

OBJECTIVE

To perform a systematic review of completion rates of cardiac rehabilitation (CR) in adults aged 18 to 50 yr and describe how core components were reported, measured, and tailored to those under 50 yr.

REVIEW METHODS

Database search of MEDLINE, Embase, Emcare, PsycINFO, CINAHL, Scopus, and the Cochrane Library based on keywords, including articles from January 1, 1990. The last search was performed on April 21, 2023. Following the Preferred Reporting Items for Systematic Review and Meta-Analyses protocol, eligible articles contained adults (aged between 18 and 50 yr) who had participated in a CR program.

SUMMARY

Out of the articles screened (n = 24,517), 33 reports across 31 independent studies were considered eligible (n = 1958 patients aged ≤50 yr). Cardiac rehabilitation completion rates ranged from 64% to 100%; however, only 5 studies presented a completion rate definition. The length of the program ranged from 7 d to 20 wk, with most (65%) ranging between 6 and 12 wk. While the studies included in this systematic review indicated relatively high rates of completing CR, these are likely to overrepresent the true completion rates as few definitions were provided that could be compared to completion rates used in clinical practice. This systematic review also found that all interventions prescribed exercise (eg, aerobic alone or combined with resistance training or yoga) but had very limited inclusion or description of other integral components of CR (eg, initial assessment and smoking cessation) or how they were assessed and individualized to meet the needs of younger attendees.

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 is not futile: a systematic review of the benefits, mechanisms and safety of resistance training in people with heart failure

Exercise offers many physical and health benefits to people with heart failure (CHF), but aerobic training (AT) predominates published literature. Resistance training (RT) provides additional and complementary health benefits to AT in people with CHF; we aimed to elucidate specific health benefits accrued, the mechanism of effect and safety of RT. We conducted a systematic search for RT randomised, controlled trials in people with CHF, up until August 30, 2023. RT offers several benefits including improved physical function (peak VO2 and 6MWD), quality of life, cardiac systolic and diastolic function, endothelial blood vessel function, muscle strength, anti-inflammatory muscle markers, appetite and serious event rates. RT is beneficial and improves peak VO2 and 6MWD, partly restores normal muscle fibre profile and decreases inflammation. In turn this leads to a reduced risk or impact of sarcopenia/cachexia via effect on appetite. The positive impact on quality of life and performance of activities of daily living is related to improved function, which in turn improves prognosis. RT appears to be safe with only one serious event reported and no deaths. Nevertheless, few events reported to date limit robust analysis. RT appears to be safe and offers health benefits to people with CHF. RT modifies the adverse muscle phenotype profile present in people with CHF and it appears safe. Starting slowly with RT and increasing load to 80% of 1 repetition maximum (RM) appears to offer optimal benefit.

Efficacy of physical exercise on the physical ability, cardiac function and cardiopulmonary fitness of patients with atrial fibrillation: a systematic review and meta-analysis

Objective

It is advised that patients engage in physical activity to enhance their quality of life and achieve better results. The purpose of the current study was to measure the efficacy of exercise on the physical ability, cardiac function and cardiopulmonary fitness of patients with AF.

Method

A comprehensive systematic literature search was performed in PubMed, Embase, and Web of Science from 1991 to 2023 for 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 physical ability (measured by the 6-min walk test, 6MWT), cardiac function (measured by left ventricular ejection fraction, LVEF) and cardiopulmonary fitness (measured by peak oxygen uptake and resting heart rate). Quality assessments were conducted using the Cochrane Collaboration tool.

Results

Thirteen trials involving 672 patients met the criteria for analysis. The results showed that physical exercise increased physical ability by improving the 6MWT (m) performance (MD = 96.99, 95% CI: 25.55-168.43; Z = 2.66; p = 0.008); and enhanced peak VO2 (ml/kg per min) (MD = 4.85, 95% CI: 1.55-8.14; Z = 2.89; p = 0.004) while reducing resting heart rate (beats per minute, bpm) (MD = -6.14, 95% CI: -11.30 to -0.98; Z = 2.33; p = 0.02). However, the results showed that regular exercise could improve LVEF (%) inpatients clinically, which had no statistic difference between experimental and control group (MD = 1.49, 95% CI: -0.25-3.24; Z = 1.68; p = 0.09).

Conclusion

Our meta-analysis shows that physical exercise is an effective intervention to improve the exercise ability and cardiopulmonary fitness for AF patients. Meanwhile, we also do not exclude the positive effect of exercise on the improvement of cardiac function (LVEF) in patients with AF. To this end, doctors should consider the positive impact of exercise on patients and give advice on exercise limits in practical clinical practice.

Associations of Dietary and Lifestyle Components with Atrial Fibrillation

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia that still remains a significant health concern, especially due to its consequences, including stroke and heart failure. This review explores the intricate interplay between AF, lifestyle choices, and dietary habits. It is particularly focused on findings from diverse studies about non-pharmacological methods of managing AF. Moreover, its purpose is to elucidate the implementation of lifestyle changes such as physical activity or proper diet choices in the integrated treatment strategy of patients with AF.

Long-Term Follow-Up of HRQoL up to Six Years after Outpatient Phase-II Cardiac Rehabilitation

Background: Low health-related quality of life (HRQoL) is associated with adverse cardiovascular outcomes in coronary heart disease (CHD) patients. Cardiac rehabilitation (CR) improves HRQoL; however, evidence on long-term HRQoL changes after CR, and their predictors, is missing. Methods: A total of 153 patients with complete HRQoL data in the short-form (SF)-36 Health Survey at CR entry, discharge and follow-up were included. Using linear mixed-effects regression models for repeated time measurements, we examined predictors of follow-up HRQoL, including age and clinical characteristics. Results: Both physical (t = -5.66, p < 0.001) and mental (t = -2.06, p = 0.040) HRQoL improved significantly from CR entry to discharge, with improvements remaining stable over a mean follow-up of four years (range 2.4-6.1). Better functional capacity (6MWT) at CR entry predicted better physical HRQoL (t = 5.50, p < 0.001) and, with a trend, better mental HRQoL (t = 1.92, p = 0.056) at follow-up. A psychiatric diagnosis at CR entry predicted better mental HRQoL at follow-up (t = 3.85, p < 0.001). Conclusions: Improvements in HRQoL during CR remain stable during long-term follow-up. Levels of functional capacity appear to be relevant to both physical and mental HRQoL at follow-up.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Cardiac telerehabilitation: current status and future perspectives

Multidisciplinary cardiac rehabilitation (CR) improves the prognosis and quality of life of patients with cardiovascular disease and has therefore received strong recommendations in international guidelines for the treatment of patients with chronic coronary syndromes and chronic heart failure. Aiming to both resolve several barriers that impede participation in CR and to improve the effectiveness of CR, cardiac telerehabilitation (CTR) has emerged as a cost-effective alternative to traditional, centre-based CR. Although the body of evidence for the feasibility and effectiveness of CTR is large and still growing, real-life implementations are scarce, which may be due to insufficient knowledge about CTR interventions and due to the challenges its implementation comes with. Up to now, mainly exercise-related core components of CR and e‑coaching have been investigated in the setting of CTR. Translation of research findings to clinical practice may be hampered by methodological limitations present in most CTR studies, being selection bias of participants, lack of long-term follow-up, heterogeneity of studied interventions and the lack of robust outcome measures. Besides conducting highly needed implementation studies for CTR interventions, their implementation could be facilitated by the development of guideline-based, multidisciplinary and personalised CTR programmes and widespread reimbursement for CTR.

Effect of Multifactorial Risk Factor Interventions on Atrial Fibrillation: A Systematic Review and Meta-Analysis

Evidence supports the benefit of managing atrial fibrillation (AF) specific risk factors in secondary prevention of AF. However, a comprehensive summary of the effect of multifactorial risk factor interventions on outcomes of patients with AF over long-term is lacking. We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases from inception to October 2021 for both randomized controlled trials (RCT) and observational studies comparing multifactorial risk factor interventions to usual care in patients with AF. Fifteen studies (10 RCT, 5 observational) with 3786 patients were included (mean age 63.8 years, 64.0% males). Follow-up ranged from 3 to 42 months. We found no significant effects of multifactorial risk factor interventions on AF recurrence [pooled relative risk (RR): 0.93, 95% CI: 0.74-1.16, P = 0.51, I² = 54%], AF-related rehospitalization at 12 months (RR: 0.69, 95% CI: 0.43-1.11, P= 0.13, I² = 0%), cardiovascular rehospitalization at 12 months (RR: 0.76, 95% CI: 0.53-1.09, P= 0.13, I² = 53%), or AF-related adverse events at 12 and 15 months. However, multifactorial interventions were associated with reduced AF-related symptoms and improved health-related quality of life (HRQoL) at all studied time points. Current evidence does not support consistent associations between multifactorial risk factor interventions and AF recurrence after rhythm control therapy or AF-related or cardiovascular hospitalization in patients with AF. However, these interventions are associated with clinically relevant improvement in AF-related symptoms and HRQoL. Additional randomized studies are required to evaluate the impact of multifactorial risk factor interventions on patient-centered health outcomes.

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.

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.

Effect of High-Intensity Interval Training in Patients With Atrial Fibrillation: A Randomized Clinical Trial

IMPORTANCE

Patients with atrial fibrillation (AF) experience poor functional capacity and quality of life (QOL). High-intensity interval training (HIIT) has been shown to elicit greater improvements in functional capacity and QOL compared with moderate to vigorous intensity continuous training (MICT) in other cardiovascular populations, yet HIIT remains understudied in AF.

OBJECTIVE

To compare the effects of 12 weeks of HIIT and MICT-based cardiovascular rehabilitation (CR) on functional capacity and general QOL in patients with persistent and permanent AF. Disease-specific QOL, resting heart rate (HR), time in AF, and physical activity (PA) levels were also assessed.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial, conducted between November 17, 2015, and February 4, 2020, at a tertiary-care cardiovascular health center in Ottawa, Canada, recruited 94 patients with persistent and permanent AF.

INTERVENTIONS

High-intensity interval training (23 minutes: two 8-minute interval training blocks of 30-second work periods at 80%-100% of peak power output interspersed with 30-second recovery) or CR (60 minutes: continuous aerobic conditioning within 67%-95% of peak HR and 12-16 of 20 ratings of perceived exertion) twice weekly for 12 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcomes were changes in functional capacity (6-minute walk test [6MWT] distance) and general QOL (Short Form 36) from baseline to 12 weeks' follow-up. Secondary outcomes included changes in disease-specific QOL (Atrial Fibrillation Severity Scale), resting HR, time in AF, and PA levels. An intention-to-treat analysis was used to compare changes between groups.

RESULTS

Of the 94 patients who consented, 86 participated (mean [SD] age, 69 [7] years; 57 [66.3%] men). No significant differences in improvements in 6MWT distance (mean [SD], 21.3 [34.1] vs 13.2 [55.2] m; P = .42) and general QOL (Physical Component Summary, 0.5 [6.1] vs 1.1 [4.9] points; P = .87) between HIIT and CR were observed. No significant differences in improvements in disease-specific QOL (AF symptoms: -1.7 [4.3] vs -1.5 [4] points, P = .59), resting HR (-3.6 [10.6] vs -2.9 [12.4] beats per minute, P = .63), and moderate to vigorous PA levels (37.3 [93.4] vs 14.4 [125.7] min/wk; P = .35) between HIIT and CR were detected. Participants attended a mean (SD) of 18.3 (6.1) (75.1%) HIIT sessions and 20.0 (4.5) (83.4%) CR sessions (P = .36).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, twice-weekly 23-minute HIIT was as efficacious as twice-weekly 60-minute CR in improving functional capacity, general and disease-specific QOL, resting HR, and PA levels in patients with persistent and permanent AF.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02602457.

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

Background

The primary goal of this study was to determine the time spent completing moderate-to-vigorous intensity physical activity (MVPA) among adults with atrial fibrillation (AF). Secondary aims examined MVPA and sitting time (ST) by AF subtypes (ie, paroxysmal, persistent, long-standing persistent, and permanent) and associations between MVPA or ST and knowledge, task self-efficacy, and outcome expectations.

Methods

An observational study was conducted in the Champlain region of Ontario, Canada. AF patients completed a survey to determine MVPA and ST using the Short-Form International Physical Activity Questionnaire.

Results

A total of 619 patients (66% male; median age 65 years [95% CI 64-67 years]) completed the survey. Median MVPA and ST were 100 (60-120) min/wk and 6 (5-6) h/d; 56% of patients were not meeting the Canadian 24H Movement Guidelines. Most patients (54%) did not know/were unsure of the MVPA recommendations, yet 72% thought physical activity should be part of AF management. Positive correlations were found between higher MVPA levels and the following: (i) speaking to a healthcare professional about engaging in physical activity for managing AF (ρ = 0.108, P = 0.017); (ii) greater confidence regarding ability to perform physical activity and muscle-strengthening exercise (ρ = 0.421, P < 0.01); and (iii) patient agreement that AF would be better managed if they were active (ρ = 0.205, P < 0.01).

Conclusions

Many AF patients do not meet the MVPA recommendations, which may be due to lack of physical activity knowledge. Exercise professionals may help educate patients on the benefits of physical activity, improve task-self efficacy, and integrate MVPA into patient lifestyles.

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.

Prognostic Utility of a New Risk Stratification Protocol for Secondary Prevention in Patients Attending Cardiac Rehabilitation

Several risk scores have been used to predict risk after an acute coronary syndrome (ACS), but none of these risk scores include functional class. The aim was to assess the predictive value of risk stratification (RS), including functional class, and how cardiac rehabilitation (CR) changed RS. Two hundred and thirty-eight patients with ACS from an ambispective observational registry were stratified as low (L) and no-low (NL) risk and classified according to exercise compliance; low risk and exercise (L-E), low risk and control (no exercise) (L-C), no-low risk and exercise (NL-E), and no-low risk and control (NL-C). The primary endpoint was cardiac rehospitalization. Multivariable analysis was performed to identify variables independently associated with the primary endpoint. The L group included 56.7% of patients. The primary endpoint was higher in the NL group (18.4% vs. 4.4%, p < 0.001). After adjustment for age, sex, diabetes, and exercise in multivariable analysis, HR (95% CI) was 3.83 (1.51−9.68) for cardiac rehospitalization. For RS and exercise, the prognosis varied: the L-E group had a cardiac rehospitalization rate of 2.5% compared to 26.1% in the NL-C group (p < 0.001). Completing exercise training was associated with reclassification to low-risk, associated with a better outcome. This easy-to-calculate risk score offers robust prognostic information. No-exercise groups were independently associated with the worst outcomes. Exercise-based CR program changed RS, improving classification and prognosis.

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.

Exercise training in cardiac rehabilitation: Setting the right intensity for optimal benefit

Cardiac rehabilitation (CR) programs are recommended standard-of-care by all major cardiovascular medicine professional organizations. Exercise training is the cornerstone for CR, with aerobic training being the primary form of training. The benefits of exercise training are multiple; however, improved cardiorespiratory fitness is of utmost importance. Moderate-intensity continuous training, supplemented with resistance training, has traditionally been the most common form of exercise training in CR. This review discusses the role of aerobic exercise training in CR and the importance of effective and personalized exercise prescription for optimized results. We also focus on the benefits and utility of high-intensity interval training across different clinical populations commonly seen in the CR setting.

Efficacy of exercise in patients with atrial fibrillation: Systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The benefits of exercise in atrial fibrillation (AF) are not clear yet. The aim was to assess the effects of exercise on functional capacity, quality of life, symptoms and adverse events in AF patients.

METHODS

Pubmed, Web of Science, Science Direct and CENTRAL databases were searched to collect the literature concerning AF and exercise. Studies using an endurance and/or strength exercise of at least one-month duration were included. The meta-analysis was conducted using the random-effects method.

RESULTS

10 randomised controlled trials were selected. The analysis reported a significant improvement in the maximum exercise capacity (SMCR=0.35; CI95%=0.18, 0.51; p<.001) after exercise intervention. In patients with paroxysmal and persistent AF, exercise improved significantly VO_2peak (SMCR=0.387; CI95%=0.214, 0.561; p<.001). Moreover, patients with permanent AF showed significant results in the 6-min walk test (SMCR=0.74; CI95%=0.31, 1.17; p<.001) and the resting heart rate (SMCR=-0.51; CI95%=-0.93, -0.10; p=.0015) thanks to exercise. Regarding quality of life, there was an improvement trend in the physical component score (SMCR=0.13; CI95%=-0.05, 0.31; p=.17) and mental component score (SMCR=0.09; CI95%=-0.09, 0.27; p=.35) in the exercise group. Nevertheless, pharmacological treatment tended to control the systolic blood pressure (SMCR=0.13; CI95%=-0.03, 0.3; p=.11).

CONCLUSION

Exercise has a beneficial role as an adjuvant treatment of AF.

A guide to the management of atrial fibrillation in Santa Claus

•In view of his advanced age and risk factors, Santa Claus is at high risk of developing atrial fibrillation. Despite this, no guidelines exist on the subject. •Following a review of the literature, we present our position on the management of atrial fibrillation in Santa Claus, and propose the use of the SANTA CLAUS mnemonic to aid clinicians: Screen for atrial fibrillation; Anticoagulate; Normalise heart rate; Treat comorbidities; Anti-arrhythmic drugs; Cardioversion; Lifestyle measures; Ablation treatment; Understand emotional and psychological impact; Save Santa Claus.

The Combined Effects of Patient Activation and Relational Aspects on the Quality of Life in Atrial Fibrillation Patients

Objective: This study aims to explore the influence of patient activation (PA) and relational aspects on the quality of life (QoL) in patients with Atrial Fibrillation (AF) for developing measures to improve PA and QoL. Methods: A cross-sectional study was undertaken in 2021 among 190 AF patients in Nanjing, China. Research instruments included a self-designed social-demographic characteristics scale, the Patient Activation Measure (PAM), the Atrial Fibrillation Effect on Quality of Life (AFEQT). The data analysis was performed using IBM SPSS 25.0. Spearman correlation analysis, multiple linear regression analysis, and Wilcoxon rank-sum tests were used to assess the association accordingly. Results: The average AFEQT score for the 190 AF patients was 69.32 ± 14.52. The distribution of activation Levels 1, 2, 3, and 4, were where 4.7, 34.2, 47.4, and 13.7%, respectively. The multiple linear regression analysis revealed that patient activation, work status, and cardiac rehabilitation of AF patients predicted AF-related QoL (β = 0.270, -0.205, and 0.183, respectively; all P < 0.05). The influences of PA level on subdimensions of AF-related QoL were as follows: symptoms, daily activities and treatment concern. Conclusion: The level of QoL of patients with AF was moderate. Higher levels of patient activation in those with AF were associated with milder symptoms, more positive daily activities and fewer treatment concern. Based on our findings, we suggest that healthcare personnel should encourage AF patients to take active participation in cardiac rehabilitation, disease self-management and foster progression of PA level. Future research is warranted to develop tailor-made interventions aimed at the activation level.

Research Priorities in the Secondary Prevention of Atrial Fibrillation: A National Heart, Lung, and Blood Institute Virtual Workshop Report

There has been sustained focus on the secondary prevention of coronary heart disease and heart failure; yet, apart from stroke prevention, the evidence base for the secondary prevention of atrial fibrillation (AF) recurrence, AF progression, and AF-related complications is modest. Although there are multiple observational studies, there are few large, robust, randomized trials providing definitive effective approaches for the secondary prevention of AF. Given the increasing incidence and prevalence of AF nationally and internationally, the AF field needs transformative research and a commitment to evidenced-based secondary prevention strategies. We report on a National Heart, Lung, and Blood Institute virtual workshop directed at identifying knowledge gaps and research opportunities in the secondary prevention of AF. Once AF has been detected, lifestyle changes and novel models of care delivery may contribute to the prevention of AF recurrence, AF progression, and AF-related complications. Although benefits seen in small subgroups, cohort studies, and selected randomized trials are impressive, the widespread effectiveness of AF secondary prevention strategies remains unknown, calling for development of scalable interventions suitable for diverse populations and for identification of subpopulations who may particularly benefit from intensive management. We identified critical research questions for 6 topics relevant to the secondary prevention of AF: (1) weight loss; (2) alcohol intake, smoking cessation, and diet; (3) cardiac rehabilitation; (4) approaches to sleep disorders; (5) integrated, team-based care; and (6) nonanticoagulant pharmacotherapy. Our goal is to stimulate innovative research that will accelerate the generation of the evidence to effectively pursue the secondary prevention of AF.

Depression and anxiety in cardiac rehabilitation: differential associations with changes in exercise capacity and quality of life

BACKGROUND

Cardiac rehabilitation (CR) has been successful in improving exercise capacity (EC) and quality of life (QoL). However, depression and anxiety are highly prevalent among cardiac patients and might represent risk factors for rehabilitation outcomes. The aim of this study was to investigate the role of depression and anxiety as possible independent risk factors for CR outcomes.

METHODS

The study applied a pre-post-design. The sample comprised N = 3'434 cardiac disease patients taking part in a Swiss inpatient CR center. Variables measured at the beginning (T1) and end of rehabilitation (T2) included depression and anxiety (HADS), EC, and QoL (MacNew). A path analysis was conducted.

RESULTS

Depression at T1 had a significant negative relationship with improvements in EC and in all aspects of QoL during rehabilitation. Anxiety at T1 was positively related to improvements in EC and in emotional and physical QoL. Improvements in depression during CR were positively related with improvements in all outcomes. Improvements in anxiety showed no significant association with the outcomes.

CONCLUSION

Depression and anxiety should be screened for during CR. Depression should be treated due to the negative association found with rehabilitation outcomes. Underlying mechanisms of the positive association of anxiety with rehabilitation outcomes need further investigation.

Novel advances in cardiac rehabilitation : Position paper from the Working Group on Preventive Cardiology and Cardiac Rehabilitation of the Netherlands Society of Cardiology

Cardiac rehabilitation (CR) has evolved as an important part of the treatment of patients with cardiovascular disease. However, to date, its full potential is fairly underutilised. This review discusses new developments in CR aimed at improving participation rates and long-term effectiveness in the general cardiac population. It consecutively highlights new or challenging target groups, new delivery modes and new care pathways for CR programmes. These new or challenging target groups include patients with atrial fibrillation, obesity and cardiovascular disease, chronic coronary syndromes, (advanced) chronic heart failure with or without intracardiac devices, women and frail elderly patients. Also, the current evidence regarding cardiac telerehabilitation and loyalty programmes is discussed as new delivery modes for CR. Finally, this paper discusses novel care pathways with the integration of CR in residual risk management and transmural care pathways. These new developments can help to make optimal use of the benefits of CR. Therefore we should seize the opportunities to reshape current CR programmes, broaden their applicability and incorporate them into or combine them with other cardiovascular care programmes/pathways.

Exercise-Based Cardiac Rehabilitation and All-Cause Mortality Among Patients With Atrial Fibrillation

Background

There is limited evidence of long‐term impact of exercise‐based cardiac rehabilitation (CR) on clinical end points for patients with atrial fibrillation (AF). We therefore compared 18‐month all‐cause mortality, hospitalization, stroke, and heart failure in patients with AF and an electronic medical record of exercise‐based CR to matched controls.

Methods and Results

This retrospective cohort study included patient data obtained on February 3, 2021 from a global federated health research network. Patients with AF undergoing exercise‐based CR were propensity‐score matched to patients with AF without exercise‐based CR by age, sex, race, comorbidities, cardiovascular procedures, and cardiovascular medication. We ascertained 18‐month incidence of all‐cause mortality, hospitalization, stroke, and heart failure. Of 1 366 422 patients with AF, 11 947 patients had an electronic medical record of exercise‐based CR within 6‐months of incident AF who were propensity‐score matched with 11 947 patients with AF without CR. Exercise‐based CR was associated with 68% lower odds of all‐cause mortality (odds ratio, 0.32; 95% CI, 0.29–0.35), 44% lower odds of rehospitalization (0.56; 95% CI, 0.53–0.59), and 16% lower odds of incident stroke (0.84; 95% CI, 0.72–0.99) compared with propensity‐score matched controls. No significant associations were shown for incident heart failure (0.93; 95% CI, 0.84–1.04). The beneficial association of exercise‐based CR on all‐cause mortality was independent of sex, older age, comorbidities, and AF subtype.

Conclusions

Exercise‐based CR among patients with incident AF was associated with lower odds of all‐cause mortality, rehospitalization, and incident stroke at 18‐month follow‐up, supporting the provision of exercise‐based CR for patients with AF.

Exercise-based cardiac rehabilitation for adults after heart valve surgery

BACKGROUND

The impact of exercise-based cardiac rehabilitation (CR) following heart valve surgery is uncertain. We conducted an update of this systematic review and a meta-analysis to assess randomised controlled trial evidence for the use of exercise-based CR following heart valve surgery.

OBJECTIVES

To assess the benefits and harms of exercise-based CR compared with no exercise training in adults following heart valve surgery or repair, including both percutaneous and surgical procedures. We considered CR programmes consisting of exercise training with or without another intervention (such as an intervention with a psycho-educational component).

SEARCH METHODS

We searched the Cochrane Central Register of Clinical Trials (CENTRAL), in the Cochrane Library; MEDLINE (Ovid); Embase (Ovid); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO); PsycINFO (Ovid); Latin American Caribbean Health Sciences Literature (LILACS; Bireme); and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science (Clarivate Analytics) on 10 January 2020. We searched for ongoing trials from ClinicalTrials.gov, Clinical-trials.com, and the World Health Organization International Clinical Trials Registry Platform on 15 May 2020.

SELECTION CRITERIA

We included randomised controlled trials that compared exercise-based CR interventions with no exercise training. Trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and had received heart valve replacement or heart valve repair. Both percutaneous and surgical procedures were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We assessed the risk of systematic errors ('bias') by evaluating risk domains using the 'Risk of bias' (RoB2) tool. We assessed clinical and statistical heterogeneity. We performed meta-analyses using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence for primary outcomes (all-cause mortality, all-cause hospitalisation, and health-related quality of life).

MAIN RESULTS

We included six trials with a total of 364 participants who have had open or percutaneous heart valve surgery. For this updated review, we identified four additional trials (216 participants). One trial had an overall low risk of bias, and we classified the remaining five trials as having some concerns. Follow-up ranged across included trials from 3 to 24 months. Based on data at longest follow-up, a total of nine participants died: 4 CR versus 5 control (relative risk (RR) 0.83, 95% confidence interval (CI) 0.26 to 2.68; 2 trials, 131 participants; GRADE quality of evidence very low). No trials reported on cardiovascular mortality. One trial reported one cardiac-related hospitalisation in the CR group and none in the control group (RR 2.72, 95% CI 0.11 to 65.56; 1 trial, 122 participants; GRADE quality of evidence very low). We are uncertain about health-related quality of life at completion of the intervention in CR compared to control (Short Form (SF)-12/36 mental component: mean difference (MD) 1.28, 95% CI -1.60 to 4.16; 2 trials, 150 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD 2.99, 95% CI -5.24 to 11.21; 2 trials, 150 participants; GRADE quality of evidence very low), or at longest follow-up (SF-12/36 mental component: MD -1.45, 95% CI -4.70 to 1.80; 2 trials, 139 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD -0.87, 95% CI -3.57 to 1.83; 2 trials, 139 participants; GRADE quality of evidence very low).  AUTHORS' CONCLUSIONS: Due to lack of evidence and the very low quality of available evidence, this updated review is uncertain about the impact of exercise-CR in this population in terms of mortality, hospitalisation, and health-related quality of life. High-quality (low risk of bias) evidence on the impact of CR is needed to inform clinical guidelines and routine practice.

Self-reported physical activity and atrial fibrillation risk: A systematic review and meta-analysis

BACKGROUND

Although physical activity (PA) is an important component of cardiovascular disease prevention and treatment, its role in atrial fibrillation (AF) risk is less well established.

OBJECTIVE

The purpose of this study was to systematically summarize the evidence pertaining to the relationship of PA and risk of AF.

METHODS

We searched the PubMed and Embase databases for prospective cohort studies reporting the risk of AF associated with a specific PA volume through March 2020. From each study, we extracted the risk associated with a given PA level, in comparison with insufficiently active ("inactive") individuals. The reported risk was normalized to metabolic equivalent of task (MET)-minutes per week. A random-effects meta-analysis was used to compare AF risk between those who met and those who did not meet PA recommendations (450 MET-minutes per week), and a dose-response analysis between the level of PA and the risk of AF was performed.

RESULTS

Fifteen studies reporting data from 1,464,539 individuals (median age 55.3 years; 51.7% female) were included. Individuals achieving guideline-recommended level of PA had a significantly lower risk of AF (hazard ratio 0.94; 95% confidence interval 0.90-0.97; P = .001). Dose-response analysis showed that PA levels up to 1900 MET-minutes per week were associated with a lower risk of AF, with less certainty beyond that level.

CONCLUSION

PA at guideline-recommended levels and above are associated with a significantly lower AF risk. However, at 2000 MET-minutes per week and beyond, the benefit is less clear.

Educational interventions to improve outcomes in patients with atrial fibrillation-a systematic review

BACKGROUND

Atrial fibrillation (AF) is an emerging epidemic associated with poor mental health and quality of life, as well as morbidity and mortality. Whilst other cardiovascular conditions have demonstrated positive outcomes from educational programmes, this approach is not well integrated in clinical practice in patients with AF. Though evidence in this area is mounting, a thorough overview seems to be lacking.

AIM

To assess benefits and harms of educational interventions compared with no intervention in adults with AF.

METHOD

A systematic review and meta-analysis were performed including the outcomes: Serious adverse events (mortality and readmission), mental health (anxiety and depression), physical capacity, quality of life and self-reported incidence of symptoms of AF. PubMed, Embase, CINAHL, Cochrane Library and PsycINFO were searched between June and august 2018. Data extraction and quality assessment were performed independently by two reviewers. The Cochrane Risk of Bias tool was applied for the randomised controlled trials and the Amstar Checklist for the systematic reviews.

RESULTS

Eight randomised controlled trials and one non-randomised interventional study were included, with a total of 2388 patients. Comparing with controls patient education was associated with a reduction in: Serious adverse events (Risk Ratio 0.78, CI 95% 0.63-0.97), anxiety with a mean difference of -0.62 (CI 95% -1.21, -0.04) and depression with a mean difference of -0.74 (CI 95% -1.34, -0.14). Health-related quality of life and physical capacity was found to increase after patient education, yet, only one study found statistically significant differences between groups. No differences were observed with regards to self-reported incidence of symptoms of AF.

CONCLUSIONS

Educational interventions significantly decrease the number of serious adverse events in patients with AF and seem to have a positive impact on mental health and self-reported quality of life. However, the evidence is limited, and more studies are warranted.

An exercise-based cardiac rehabilitation programme for AF patients in the NHS: a feasibility study

There is increasing evidence for the role of exercise-based cardiac rehabilitation in the management of patients with atrial fibrillation (AF). However, this intervention has not yet been widely adopted within the National Health Service (NHS). We performed a feasibility study on the utilisation of an established NHS cardiac rehabilitation programme in the management of AF, and examined the effects of this intervention on exercise capacity, weight, and psychological health. We then identified factors that might prevent patients from enrolling on our programme. Patients with symptomatic AF were invited to participate in an established six-week exercise-based cardiac rehabilitation programme, composed of physical activity and education sessions. At the start of the programme, patients were weighed and measured, performed the six-minute walk test (6MWT), completed the Generalised Anxiety Disorder Questionnaire (GAD-7), and the Patient Health Questionnaire (PHQ-9). Measurements were repeated on completion of the programme. Over two years, 77 patients were invited to join the programme. Twenty-two patients (28.5%) declined participation prior to initial assessment and 22 (28.5%) accepted and attended the initial assessment, but subsequently withdrew from the programme. In total, 33 patients completed the entire programme (63.9 ± 1.7 years, 58% female). On completion, patients covered longer distances during the 6MWT, had lower GAD-7 scores, and lower PHQ-9 scores, compared with their baseline results. Compared with patients that completed the entire programme, those who withdrew from the study had, at baseline, a significantly higher body mass index (BMI), covered a shorter distance during the 6MWT, and had higher PHQ-9 and GAD-7 scores. In conclusion, enrolling patients with AF into an NHS cardiac rehabilitation programme is feasible, with nearly half of those invited completing the programme. In this feasibility study, cardiac rehabilitation resulted in an improved 6MWT, and reduced anxiety and depression levels, in the short term. Severe obesity, higher anxiety and depression levels, and lower initial exercise capacity appear to be barriers to completing exercise-based cardiac rehabilitation. These results warrant further investigation in larger cohorts.