Updated Evidence Favors Structured Exercise Programs for Atrial Fibrillation

 

• The clinical benefits of exercise-based cardiac rehabilitation have been less clear for patients with Afib.
• A meta-analysis of 20 small randomized trials showed that exercise-based cardiac rehabilitation was effective for this population.
• There was no increase in serious adverse events observed with cardiac rehabilitation relative to controls.

Evidence indicated that exercise-based cardiac rehabilitation had benefits for patients with atrial fibrillation (Afib or AF) in an updated meta-analysis.

Across randomized trials, participants in rehab programs had significant improvements in Afib symptom severity, burden, episode frequency, episode duration, and recurrence over a mean follow-up of 11 months.

Exercise-based cardiac rehabilitation did not have an impact on all-cause mortality (relative risk [RR] 1.06, 95% CI 0.76-1.48), but did improve exercise capacity (VO₂ peak mean difference 3.18 mL/kg/min, 95% CI 1.05-5.31) relative to controls, according to researchers led by Benjamin Buckley, PhD, of the Liverpool Centre for Cardiovascular Science at the University of Liverpool in England, in the British Journal of Sports Medicineopens in a new tab or window.

Additionally, there was benefit observed for the mental component, but not the physical component, of a health-related quality-of-life questionnaire.

"Our results have clinical significance," Buckley and colleagues wrote, noting that the demonstrated improvement in mean pooled VO₂ peak was not only statistically significant, "but also clinically important, given a 1 mL/kg/min improvement has traditionally been accepted as a clinically meaningful change."

"Although further research is needed, meta-regression indicated that the effects were consistent across a range of patient and intervention characteristics (for exercise capacity). AF management guidelines should reflect this updated evidence base by recommending ExCR [exercise-based cardiac rehabilitation] alongside drug and ablation therapies for patients with AF," they concluded.

In the U.S., cardiac rehabilitation is required to includeopens in a new tab or window physician-prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Programs have been associated with clinical benefits following myocardial infarction, percutaneous coronary intervention, and heart failure, though it is considered less established for the Afib population.

That omission of physical exercise in Afib management may be on its way out.

In an accompanying editorialopens in a new tab or window, Sarandeep Marwaha, MBBS, and Sanjay Sharma, MD, both of City St. George's University of London, noted that "exercise is widely recognized as an important management tool, and it is crucial to highlight that it remains one of the most cost-effective, readily available and manageable interventions for improving cardiovascular health."

This study "reinforces the invaluable role that physical activity plays in managing AF," they added. "By prioritizing exercise, healthcare providers can offer an accessible strategy for improving outcomes."

Notably, the study authors added, there was no increase in serious adverse events observed with cardiac rehabilitation (2.9% vs 4.1%, RR 1.30, 95% CI 0.66-2.56) relative to controls.

"Patients may fear that exercise can trigger AF episodes, especially those with underlying heart conditions and clinicians will often underemphasize exercise guidance and exercise prescriptions due to uncertainty," Marwaha and Sharma wrote. "However, most studies evaluating moderate exercise in patients with AF have demonstrated safety with a very low risk of adverse events."

"Despite variability in exercise protocols, overall evidence supports tailored exercise as part of comprehensive AF management. Exercise has been shown to reduce symptoms and arrhythmia occurrence among AF patients," they continued.

For their meta-analysis, Buckley and colleagues included 20 typically small, single-center randomized studies of patients with Afib (n=2,039); 73% were men, and mean age was 63 years.

The exercise training interventions tested ranged in duration, frequency, session length, remote versus in-person, and intensity. All trials had a control arm with no formal exercise training. Four out of the 20 trials reported Afib recurrences using Holter monitors.

Study results were about the same no matter the Afib subtype, dose of exercise, or mode of rehab administered to patients.

Even so, Buckley's group cautioned that the findings may not be generalizable to various groups, since 55% of trials had been conducted in Europe and women were under-represented. The studies, unblinded and thus potentially subject to bias, also had few events to power the statistical analyses.

Disclosures

Buckley has received investigator-initiated research grants from Bristol Myers Squibb/Pfizer and Huawei EU, and consultancy fees from Huawei EU.

Co-authors reported relationships with Bristol-Myers Squibb, Pfizer, Bayer, Boehringer Ingelheim, Daiichi Sankyo, and Medtronic.

Marwaha and Sharma had no disclosures.

Primary Source

British Journal of Sports Medicine

Source Reference: opens in a new tab or windowBuckley BJR, et al "Exercise based cardiac rehabilitation for atrial fibrillation: Cochrane systematic review, meta-analysis, meta-regression and trial sequential analysis" Br J Sports Med 2025; DOI: 10.1136/bjsports-2024-109149.

Secondary Source

British Journal of Sports Medicine

Source Reference: opens in a new tab or windowMarwaha S, Sharma S "Role of exercise in atrial fibrillation management" Br J Sports Med 2025; DOI: 10.1136/bjsports-2025-110191.

https://www.medpagetoday.com/cardiology/arrhythmias/116725