Buckley, B, Long, L, Risom, S, Lane, DA, Berg, S, Gludd, C, Johansen, P, Sibilitz, K, Svendsen, J, Zwisler, A-D, Lip, GYH, Neubeck, L and Taylor, R (2024) Exercise-based cardiac rehabilitation for adults with atrial fibrillation. Cochrane Database of Systematic Reviews. ISSN 1469-493X

Text COCHRANEEMD-2023-00963_R2.pdf - Accepted Version Restricted to Repository staff only until 17 September 2025. Download (1MB)

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. This 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 patients with AF or those undergoing routine treatment for the condition. Objectives To assess the benefits and harms of ExCR for people with AF or treated for AF, compared with non-exercise controls. Search methods The following electronic databases were searched; CENTRAL and the Database of Abstracts of Reviews of Effectiveness (DARE) 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 11 December 2023. We also checked the bibliographies of relevant systematic reviews identified by the searches. No language restrictions were imposed. Selection criteria Randomised clinical trials (RCT) were included that investigated ExCR interventions compared with any type of non-exercise control. Trials included adults aged ≥18 years with any subtype of AF or those who had received treatment for AF. Data collection and analysis Five authors independently screened and extracted data in duplicate. Risk of bias was assessed using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Clinical and statistical heterogeneity were assessed by visual inspection of the forest plots, and by using standard Chi² and I² statistics. Meta-analyses were performed using random-effects models for continuous and dichotomised outcomes. Standardised mean differences were calculated where different scales were used for the same outcome. The GRADE methodology was used to rate the quality of evidence. Main results A total of 20 trials were included with 2,039 participants with AF. All trials were conducted between 2006 and 2023 with the follow-up period ranging from 8-weeks to 5 years. Certainty of evidence ranged from moderate to very low. In 13 trials, the intervention consisted of aerobic exercise (two of which consisted of yoga and one Qi-gong). Six trials consisted of a combination of aerobic and resistance exercise. One trial consisted of inspiratory muscle training. Five trials investigated comprehensive ExCR programmes. The overall risk of bias was mixed for included studies. Details of random sequence generation, allocation concealment, and use of intention to treat analyses were typically poorly reported. Evidence from nine trials (n = 1,173) suggested little to no difference in mortality between ExCR and non-exercise controls (relative risk (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; deaths = 101), low-quality GRADE evidence. The evidence from ten trials (n = 825) is very uncertain on the effect of ExCR on serious adverse events (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; events = 28), very low-quality GRADE evidence. Evidence from four trials (n = 378) showed ExCR likely reduced the recurrence of AF (measured via holter monitoring) compared to controls (RR 0.70, 95%CI 0.56 to 0.88; I² = 2%), moderate-quality GRADE evidence. ExCR may reduce AF symptom severity (n=600, MD -1.59, 95%CI -2.98 to -0.20; I2 = 61%, low-quality GRADE evidence), likely reduce AF symptom burden (n=317, MD -1.61, 95%CI -2.76 to -0.45; I2 = 0%, moderate-quality GRADE evidence), may reduce AF episode frequency (n=368, MD -1.29, 95%CI -2.50 to -0.07; I2 = 0%, low-quality GRADE evidence), and likely reduce AF episode duration (n=317, MD -0.58, 95%CI -1.14 to -0.03; I2 = 0%, moderate-quality GRADE evidence), measured via the AF Symtom Severity (AFSS) questionnaire. Moderate quality GRADE evidence from six trials (n = 504) showed ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) for the Short Form-36 (SF-36)(MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on physical component summary measure is very uncertain (mean difference (MD) 1.75, 95% CI -0.31 to 3.81; I² = 52%), very low-quality GRADE evidence. ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (VO2peak and six minute walk) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre vs. home-based, exercise dose, exercise only vs. comprehensive programmes, and aerobic training alone vs 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. The evidence showed ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as mental components of HRQoL. ExCR may improve AF symtom 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.

Item Type:	Article
Uncontrolled Keywords:	11 Medical and Health Sciences; 17 Psychology and Cognitive Sciences; General & Internal Medicine
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine R Medicine > RC Internal medicine > RC1200 Sports Medicine R Medicine > RM Therapeutics. Pharmacology
Divisions:	Nursing & Allied Health Sport & Exercise Sciences
Publisher:	Cochrane Collaboration
SWORD Depositor:	A Symplectic
Date Deposited:	15 Jul 2024 10:29
Last Modified:	24 Sep 2024 10:15
DOI or ID number:	10.1002/14651858.CD011197.pub3
URI:	https://researchonline.ljmu.ac.uk/id/eprint/23734

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