ACTIVE-AF Suggests Physical Activity May Reduce Atrial Fibrillation Risk

Prashanthan Sanders, MBBS, PhD

New findings from the ACTIVE-AF study indicate an exercise-based intervention reduced arrhythmia recurrence among patients with paroxysmal or persistent, symptomatic atrial fibrillation (AF).

The ACTIVE-AF six-month intervention combining supervised exercise and home-based physical activity led to a reduction in self-reported AF symptom severity and improved the maintenance of sinus rhythm without antiarrhythmic medication or AF ablation.

“Our primary findings expand on those from smaller randomized controlled trials with short follow-up and large observational studies, showing improved AF symptoms coupled with reduced AF burden and recurrence,” wrote corresponding author Prashanthan Sanders, MBBS, PhD, Centre for Heart Rhythm Disorders, University of Adelaide. “This study reaffirms the role of lifestyle modification for patients in the management of AF.”

Aggressive management of modifiable risk factors has been shown to limit the progression of AF and promote the long-term maintenance of sinus rhythm. Physician inactivity may play a role in the development of AF, but there is a shortage of data addressing the clinical benefits, including arrhythmia recurrence, of exercise training in the long-term management of nonpermanent AF, particularly in the context of a randomized controlled trial.

Sanders and the team hypothesized that a combined home and supervised exercise and physical activity intervention would reduce arrhythmia recurrence and lower symptom severity. The study tested the efficacy of a six-month intervention, combining supervised exercise with home-based physical activity on AF symptom severity, and AF recurrence during and beyond completion of the exercise intervention.

The ACTIVE-AF trial recruited patients with symptomatic paroxysmal or persistent AF allocated to receive an exercise intervention or usual medical care for a period of 6 months with 6 months of follow-up. Exercise interventions were tailored for each patient based on baseline exercise capacity and current physical activity levels and preferences and delivered by clinical exercise physiologists. Those in the control group were given two one-on-one educational sessions with a clinical exercise physiologist on the benefits of physical activity participation and appropriate guidance on exercise for patients with AF.

Coprimary outcomes for the study were freedom from AF, off antiarrhythmic medications and without AF ablation, and AF symptom severity, quantified using the symptom severity domain of the University of Toronto Atrial Fibrillation Symptom Severity (AFSS) Questionnaire.

From November 2015 to December 2019, a total of 369 patients with symptomatic AF were assessed for eligibility and 120 of these patients were enrolled in the study. At 12 months, in an intention-to-treat analysis, the proportion of patients free from arrhythmia at final follow-up, was 40% (24 of 60 patients) in the exercise group and 12 (20%) of 60 patients in the control group (HR, 0.50; 95% CI, 0.33 to 0.78).

At the six-month mark, the mean difference in symptom severity between groups at 12 months was –2.3 points (95% CI, -4.3 to -0.2; P = .033) in favor of the exercise group. The difference continued at 12 months (–2.3; 95% CI, –4.5 to –0.1; P = .041).

Moreover, total symptom burden was lower at 6 months in the exercise group, compared to the control group (mean difference, -2.0; 95% CI, -3.7 to -0.3). At 12 months, the mean difference was -1.7 points (95% CI, -3.6 to 0.2).

Peak oxygen consumption was higher in the exercise group at both 6 and 12 months. After 6 months, there were no between-group differences in weight, body mass index, systolic blood pressure, or diastolic blood pressure.

Based on these data, investigators support the “recommendation of exercise prescription within the medical care of prescription within the medical care of patients with AF to improve AF-related symptoms and reduce arrhythmia recurrence.”

The study, “An Exercise and Physical Activity Program in Patients With Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial,” was published in JACC: Clinical Electrophysiology.