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Meta-Analysis
. 2024 Sep 17;9(9):CD011197.
doi: 10.1002/14651858.CD011197.pub3.

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

Benjamin JR Buckley  1   2 , Linda Long  3 , Signe S Risom  4 , Deirdre A Lane  1   5 , Selina K Berg  6   7   8   9 , Christian Gluud  10   11 , Pernille Palm  6 , Kirstine L Sibilitz  12 , Jesper H Svendsen  6   7 , Ann-Dorthe Zwisler  13 , Gregory YH Lip  1   5 , Lis Neubeck  14 , Rod S Taylor  9   15
Affiliations
Meta-Analysis

Exercise-based cardiac rehabilitation for adults with atrial fibrillation

Benjamin JR Buckley et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

Benjamin Buckley: has received research funding from Bristol Myers Squibb (BMS) and Pfizer outside of this work.

Linda Long: none known.

Signe Risom: received travel funds from Boston Scientific Corporation to attend European Society of Cardiology annual meeting in Amsterdam.

Deirdre Lane: has received investigator‐initiated educational grants from BMS and Pfizer; has been a speaker for Bayer, Boehringer Ingelheim, and BMS/Pfizer; and has consulted for BMS and Boehringer Ingelheim, all outside the submitted work.

Selina Berg: none known.

Christian Gluud: is a Cochrane editor and was not involved in the editorial process.

Pernille Palm: has received speaker fees from Boehringer Ingelheim and Novartis.

Kirstine Sibilitz: none known.

Jesper Svendsen: has received institutional research grants from European Union (Horizon 2020 and EUROSTARS), Innovation Fund Denmark, and Medtronic; Speaker fees from Medtronic; and Honorarium for membership of Advisory Boards in Medtronic and Vital Beats.

Ann‐Dorthe Zwisler: none known.

Gregory Lip: is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi‐Sankyo, Anthos. No fees are received personally. He is a National Institute for Health and Care Research (NIHR) Senior Investigator.

Lis Neubeck: has received research funding from Daiichi Sankyo Company.

Rod Taylor: none known.

Figures

1
1
PRISMA flow diagram of search results. Created by BB.
2
2
Summary of risk of bias by each assessed component.
3
3
Summary of risk of bias for each component assessed for each trial.
1.1
1.1. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 1: Mortality
1.2
1.2. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 2: Serious adverse events
1.3
1.3. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 3: AF recurrence
1.4
1.4. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 4: AFSS symptom severity
1.5
1.5. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 5: AFSS symptom burden
1.6
1.6. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 6: AFSS episode frequency
1.7
1.7. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 7: AFSS episode duration
1.8
1.8. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 8: Quality of life, SF‐36 mental component score
1.9
1.9. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 9: Quality of life, SF‐36 physical component score
1.10
1.10. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 10: Quality of life, SF‐36 physical function
1.11
1.11. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 11: Quality of life, SF‐36 physical role functioning
1.12
1.12. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 12: Quality of life, SF‐36 bodily pain
1.13
1.13. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 13: Quality of life, SF‐36 general health
1.14
1.14. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 14: Quality of life, SF‐36 vitality
1.15
1.15. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 15: Quality of life, SF‐36 social functioning
1.16
1.16. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 16: Quality of life, SF‐36 role emotional
1.17
1.17. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 17: Quality of life, SF‐36 mental health
1.18
1.18. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 18: Exercise capacity (VO2peak)
1.19
1.19. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 19: Exercise capacity (6MWT)
1.20
1.20. Analysis
Comparison 1: Exercise‐based cardiac rehabilitation versus no exercise up to 12 months' follow‐up, Outcome 20: Exercise capacity (SMD)
See this image and copyright information in PMC

Update of

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References to ongoing studies

DRKS00017836 {published data only}
    1. DRKS00017836. High-Intensity Interval Training prior to Pulmonary Vein Ablation in the Treatment of Atrial Fibrillation - a prospective, randomized controlled trial: Prehabilitation Study of the Cologne ExAfib Trial - ExAfib-Prehab. https://drks.de/search/en/trial/DRKS00017836.
ISRCTN16703816 {published data only}
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NCT04092166 {published data only}
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NCT04190212 {published data only}
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NCT04600713 {published data only}
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NCT05354271 {published data only}
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