Aerobic Exercise Can Reduce AF Frequency, Severity: ACTIVE-AF

Marlene Busko

August 26, 2021

Patients with atrial fibrillation (AF) gained significant benefits from a 6-month program of supervised and unsupervised moderate exercise vs usual care, new randomized trial results show.  

Among 120 AF patients in the ACTIVE-AF trial, those randomized to the exercise arm had significantly less frequent AF recurrence and less severe symptoms over a 1-year period, said Adrian Elliott, PhD, who will present this late-breaking research at the European Society of Cardiology (ESC) Congress 2021.

The trial "demonstrates that some patients can control their arrhythmia through physical activity, without the need for complex interventions such as ablation or medications to keep their heart in normal rhythm," Elliott, from the University of Adelaide, Australia, said in a statement from the ESC.

This is "the largest randomized controlled trial investigating the value of an exercise prescription in patients with symptomatic paroxysmal or persistent AF," he told theheart.org | Medscape Cardiology in an email.

The findings "really provide the evidence needed that recommending aerobic exercise in patients with symptomatic AF can lower the severity of symptoms and prevent the recurrence of AF for many patients," he said. Aerobic exercise should be incorporated into patient treatment, he added, "alongside the use of medications, as guided by a cardiologist, and management of obesity, hypertension and sleep apnea."

Mina K. Chung, MD, lead author of a Scientific Statement from the American Heart Association (AHA) on Lifestyle and Risk Factor Modification for Reduction of Atrial Fibrillation, as previously reported by Medscape, agrees.

The "findings support the AHA Scientific Statement that we should encourage our patients with AF to include regular moderate exercise to help prevent AF, reduce AF burden, and improve AF-related symptoms and quality of life," Chung, a cardiologist at the Cleveland Clinic in Ohio, summarized in an email to theheart.org | Medscape Cardiology.

"Our recommendation is to encourage AF patients to aim for at least the AHA physical activity guidelines for the general population, which advise 150 minutes each week of moderate-intensity exercise," Chung said.

This is a "reasonable" goal, but "some might argue that a slightly higher target of physical activity duration may be considered," Elliott commented.

ACTIVE-AF, he noted, suggests that "as a general guide, patients [with AF] should strive to build up to 3.5 hours per week of aerobic exercise and incorporate some higher intensity activities to improve cardiorespiratory fitness."

Aim for 3.5 Hours a Week

A previous observational study showed that patients who improved their cardiorespiratory fitness over a 5-year period were significantly less likely to have AF recurrences.

And in a randomized trial of 51 patients, 12 weeks of aerobic interval training reduced the time spent in AF compared to usual care, during a 4-week follow-up.

ACTIVE-AF aimed to investigate the value of exercise in AF in a larger, longer randomized trial.

The researchers enrolled 120 patients with an average age of 65 years, of whom 43% were women.

Patients in the treatment group received individualized guided exercise from an exercise physiologist in the cardiology clinic once a week for 3 months, and then every second week for the following 3 months along with a physical activity plan to follow at home for the other days — aiming to build up to 3.5 hours of physical activity a week.

The supervised sessions, Elliott explained, were typically higher intensity to raise cardiorespiratory fitness, while the home-based exercise was a moderate intensity aerobic activity of the patient's choice, such as walking, indoor cycling, or swimming.

"We certainly cautioned against far exceeding this level," he added.

Patients in the usual care group received exercise advice but no active intervention.

All patients received usual medical care from their cardiologist who was blinded to the study group allocation.

The co-primary outcomes were AF symptom severity score and the percentage of patients with recurrent AF at 12 months, defined as having an AF episode that lasted longer than 30 seconds or undergoing ablation or requiring ongoing anti-arrhythmic drug therapy.

At 12 months, the percentage of patients with AF recurrence was significantly lower in the exercise group than in the control group (60% vs 80%; hazard ratio, 0.50; 95% CI, 0.33 - 0.78; P = .002).

This means that more patients in the exercise group had a normal heart rhythm without needing an invasive intervention (ablation) or continued use of drugs, Elliott stressed.

Patients in the exercise group also had significantly less severe symptoms — palpitations, shortness of breath, and fatigue — than patients in the control group.

"On average, patients were achieving close to 180 minutes [of physical activity] per week by 6 months of the intervention and attended 18 supervised sessions in the clinic," Elliott said.

Cost was not a barrier since the sessions with an exercise physiologist were free.

Lack of time was the most common reason for missing the physical activity targets, especially for patients with work and family commitments.

Most patients liked the variety of physical activity options.

The researchers plan to determine any gender differences in ACTIVE-AF.

Further research is needed, Elliott added, to determine which type of exercise is best, whether exercise plus weight loss is synergistic, and whether exercise leads to better long-term freedom from arrhythmia, reduced hospitalization, and improved survival.

The study was partially supported by the National Heart Foundation of Australia through a postdoctoral fellowship to Elliott. The researchers and Chung have disclosed no relevant financial relationships.  

European Society of Cardiology (ESC) Congress 2021: ACTIVE-AF: A randomised controlled trial of exercise training in AF patients. Presented August 27, 2021.

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