Effect of exercise training with consideration of potential moderating variables in patients with atrial fibrillation: a systematic review and meta-analysis

Abstract

Background Exercise-based cardiac rehabilitation (CR) shows promise as an adjunctive treatment for patients with atrial fibrillation (AF). Previous evidence has highlighted its beneficial impact in this population. However, studies exhibit significant heterogeneity and often fail to differentiate between AF types. Furthermore, the specific influence of training variables such as exercise modality or intensity on the exercise-induced effects remains unclear. Therefore, the aim of our review was to assess the effect of exercise training (i.e., aerobic, resistance, and combined exercise), on exercise capacity, quality of life (QoL), resting heart rate (HR), AF burden, and symptoms in AF. Methods Electronic searches were conducted in Pubmed, Embase, and Web of Science up to November 2023. Standardised mean difference (SMD) or mean difference (MD) were estimated in controlled and parallel-arm studies. Effect size indices were pooled using a random-effects model when at least three studies reported a specific outcome. Additionally, subgroup analyses were carried out based on AF type. Results Most of the studies used moderate intensity exercise (MIE). The results showed that aerobic exercise improves peak oxygen uptake (VO₂ peak) to a greater extent than usual care, with higher increase in permanent AF (MD = 4.55 [CI = 3.33; 5.78] ml/kg/min) than non-permanent AF (MD + = 1.60 [CI = 1.12; 2.07] ml/kg/min). Compared to usual care, aerobic exercise only diminished resting HR in non-permanent AF (MD+ = − 12.79 [CI = − 15.90: − 9.67] bpm). No differences were found for improving QoL and 6-min walk test (6MWT) (p > .050). The effect of exercise on AF burden and symptoms has been poorly studied. No pooled analyses were performed by including parallel-arm studies. The findings showed no influence of the aerobic intensity or modality. Conclusion Aerobic exercise improves VO₂ peak in patients with permanent and non-permanent AF. MIE reduces resting HR in patients with permanent AF, while no differences were found in non-permanent AF. In contrast, CR does not demonstrate superior improvements in the 6MWT or QoL compared to usual care. Further research is needed to determine the impact of CR on AF burden and symptoms, and to elucidate how exercise modality and intensity influence outcomes.