Exercise-based cardiac rehab cuts atrial fibrillation recurrence and boosts quality of life, study finds

By Tarun Sai LomteReviewed by Susha Cheriyedath, M.Sc.Jul 31 2025

New research shows that exercise-based cardiac rehab offers real benefits for people with atrial fibrillation, reducing the risk of recurrence and improving mental well-being, highlighting the need for wider adoption of these programs.

Study: Exercise based cardiac rehabilitation for atrial fibrillation: Cochrane systematic review, meta-analysis, meta-regression and trial sequential analysis. Image Credit: Lightspring / Shutterstock

In a recent study published in the British Journal of Sports Medicine, researchers examined the impact of exercise-based cardiac rehabilitation (ExCR) for atrial fibrillation (AF) patients.

AF is the most common cardiac arrhythmia, with an estimated six to 12 million people projected to develop AF in the US by 2050 and 17.9 million in Europe by 2060. It is also a major risk factor for ischemic stroke, constituting a significant economic burden. Although current treatments can effectively control symptoms and stroke risk in AF, self-management interventions could be key to managing arrhythmia progression and maintaining health-related quality of life (HRQoL) and functional capacity.

ExCR is a comprehensive intervention involving exercise training, personalized lifestyle risk factor management, medical risk management, health behavior education, and psychosocial intervention. Current AF management guidelines do not recommend ExCR as the benefits of exercise for individuals with AF remain unclear. Previously, the authors reported improvements in functional capacity with ExCR in AF patients, but the impact of ExCR on clinical events was uncertain.

About the study

In the present Cochrane study, researchers systematically reviewed and meta-analyzed the impact of ExCR for AF patients. Electronic databases (CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Web of Science Core Collection, LILACS) and trial registers were searched for relevant RCTs from inception to March 2024.

Eligible studies included adults with AF, exercise-based interventions (including center-based, hybrid, or home-based programs like yoga or Qigong), a control arm, and the following outcomes: mortality, serious adverse events, AF recurrence, AF symptom severity, AF burden, HRQoL, and exercise capacity. Exercise-based intervention was any outpatient, inpatient, home-based, or community rehabilitation program that must include an exercise component and may also include a psycho-educational component.

A control arm may include no intervention, usual treatment, or another cardiac rehabilitation program without exercise. Data were extracted from trials, and the risk of bias was assessed using Cochrane’s risk of bias-1 tool. Pooled effect sizes were calculated using the standardized mean difference. GRADE and RTSA were used to evaluate evidence certainty and required sample sizes.

Findings

The database search identified 6,063 records. Of these, 4,538 unique studies were screened, resulting in the full-text analysis of 51 studies. This review included 20 RCTs conducted from 2006 to 2024, encompassing 2,039 individuals with AF with a mean follow-up of 11 months. Notably, 73% of participants were male, limiting generalizability to women. Most RCTs were conducted in Europe (10), followed by Asia (four), and Australia (two). Follow-up duration lasted from eight weeks to five years.

Six RCTs included participants with permanent AF, four included those with paroxysmal AF, and nine included those with persistent or sustained AF. The mean age of participants was 63. Five RCTs assessed comprehensive ExCR, while other trials assessed exercise-only cardiac rehabilitation. All trials included a "no formal exercise training" control arm, involving education, usual medical care, and psychological intervention.

The exercise interventions differed in frequency, duration, intensity, and session length. The risk of bias was mixed for the trials. All-cause mortality was reported in nine trials. No difference was observed in mortality between ExCR and controls, though evidence certainty was low. Ten RCTs reported serious adverse events, and there was no difference between ExCR and controls with very low certainty evidence. AF recurrence was reported in four trials; there was moderate-certainty evidence of a benefit of ExCR compared to controls.

AF symptom severity was reported in five trials and showed benefits from ExCR compared to controls with low certainty. Likewise, AF burden showed benefits with ExCR versus controls with moderate certainty. Fourteen RCTs included a validated HRQoL measure. The short-form 36 (SF-36) mental component demonstrated benefit with ExCR compared to controls with moderate certainty, while the physical component showed no significant improvement (very low certainty). Exercise capacity was reported as maximal oxygen consumption (VO₂ peak) and the six-minute walk test. ExCR showed a clinically meaningful benefit on VO₂ peak compared to controls (mean improvement 3.18 mL/kg/min, exceeding the 1 mL/kg/min threshold for clinical significance).

Discussion Context

The authors note a U-shaped relationship between exercise and AF risk, where excessive endurance exercise may increase AF prevalence in athletes, though this subgroup is unlikely to attend ExCR. GRADE and RTSA assessments indicated low-to-moderate certainty for most outcomes, underscoring the need for larger trials. Based on these findings, they suggest clinical guidelines should incorporate ExCR alongside standard AF therapies.

Conclusion

In sum, ExCR resulted in lower disease burden, recurrence, and severity, and improved exercise capacity and HRQoL mental components in individuals with AF. The effects of ExCR were consistent across RCTs, regardless of participant characteristics, nature of intervention, and AF subtype. The study’s limitations include clinical heterogeneity, predominant male representation, publication bias for exercise capacity measures, and reporting bias (due to self-reported outcomes). Future research should prioritize representative recruitment of women and diverse ethnic groups.