What exercise recommendations are suitable for patients with atrial fibrillation (afib)?

Exercise Recommendations for Patients with Atrial Fibrillation

Regular moderate physical activity is recommended for patients with atrial fibrillation to improve exercise capacity, control ventricular rate, reduce AF recurrence, and improve symptoms. 1

Assessment Before Exercise Prescription

Before prescribing exercise to AF patients:

1. Evaluate the presence and severity of underlying heart disease 1

   • Assess for structural heart disease using echocardiography
   • Evaluate left ventricular function
   • Rule out significant valvular heart disease

2. Determine rate control adequacy 1

   • Perform exercise testing to evaluate heart rate response
   • Consider 24-hour Holter monitoring to assess rate control throughout daily activities

3. For patients with devices (pacemakers/ICDs) 1

   • Know the programmed device's cutoff rate
   • Limit exercise to a heart rate at least 10-15 beats lower than the threshold discharge rate for ICDs

Exercise Recommendations

Type of Exercise

• First-line recommendation: Light to moderate physical activities, particularly leisure-time activity and walking 1

• Structured exercise program: A tailored exercise program combining aerobic and resistance training is recommended for patients with paroxysmal or persistent AF 1, 2

• Specific exercise modalities:

  • Moderate-intensity continuous training (MICT) is currently the most favored exercise therapy for AF patients 3
  • High-intensity interval training (HIIT) shows promise but should be used selectively 3

Exercise Intensity

• Target intensity: Moderate-intensity exercise (40-60% of peak exercise capacity) 1, 4

• Rate control targets during exercise:

  • 90-115 beats per minute during moderate exercise 1
  • Stay at least 10-15 beats below ICD threshold discharge rate (if applicable) 1

• Monitoring intensity:

  • For patients with fixed-rate pacemakers: Use Rating of Perceived Exertion (RPE) or systolic blood pressure rather than pulse counting 1
  • For patients without pacemakers: Heart rate monitoring is appropriate

Exercise Duration and Frequency

• Duration: 150-300 minutes per week of moderate-intensity aerobic activity 4

• Frequency: Regular, consistent exercise sessions distributed throughout the week 4, 2

Special Considerations

Cautions

• Excessive endurance exercise: Avoid high-intensity/high-volume endurance training, as it may increase the incidence of AF 1, 5, 6

• Patients with Wolff-Parkinson-White syndrome: Exercise should be approached with caution and only after appropriate treatment of the accessory pathway 1

• Heart failure patients with AF:

  • HFpEF: Beta-blockers or non-dihydropyridine calcium channel blockers are recommended for rate control 1
  • HFrEF: Beta-blockers and/or digoxin are preferred for rate control 4

Benefits of Exercise in AF

• Reduces AF recurrence and symptom burden 2
• Improves exercise capacity and cardiorespiratory fitness 2, 7
• Controls ventricular rate during AF 1
• May help prevent AF incidence in the general population 1, 5

Implementation Approach

1. Start conservatively: Begin with light to moderate activities and gradually increase intensity and duration

2. Regular reassessment: Evaluate symptoms and exercise tolerance periodically 1

3. Adjust pharmacological treatment: Modify rate control medications based on exercise response 1

4. Weight management: Combine exercise with weight loss for overweight/obese individuals with AF (target ≥10% reduction in body weight) 1

5. Alcohol reduction: Limit alcohol consumption to ≤3 standard drinks (≤30 grams) per week as part of comprehensive risk factor management 1

The most recent evidence strongly supports that a structured exercise program combining aerobic and resistance training significantly reduces AF recurrence and improves symptoms in patients with AF 1, 2. This approach should be considered an essential component of comprehensive AF management.