Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital, Liverpool, UK.
Cardiovascular Health Sciences, Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpoool, UK.
Cochrane Database Syst Rev. 2024 Sep 17;9(9):CD011197. doi: 10.1002/14651858.CD011197.pub3.
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. The 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 people with AF or those undergoing routine treatment for the condition.
To assess the benefits and harms of ExCR compared with non-exercise controls for people who currently have AF or who have been treated for AF.
We searched the following electronic databases: CENTRAL 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 24 March 2024. We imposed no language restrictions.
We included randomised clinical trials (RCTs) that investigated ExCR interventions compared with any type of non-exercise control. We included adults 18 years of age or older with any subtype of AF or those who had received treatment for AF.
Five review authors independently screened and extracted data in duplicate. We assessed risk of bias using Cochrane's RoB 1 tool as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots and by using standard Chi² and I² statistics. We performed meta-analyses using random-effects models for continuous and dichotomised outcomes. We calculated standardised mean differences where different scales were used for the same outcome. We used the GRADE approach to assess the certainty of the evidence.
We included 20 RCTs involving a total of 2039 participants with AF. All trials were conducted between 2006 and 2024, with a follow-up period ranging from eight weeks to five years. We assessed the certainty of evidence as moderate to very low. Five trials assessed comprehensive ExCR programmes, which included educational or psychological interventions, or both; the remaining 15 trials compared exercise-only cardiac rehabilitation with controls. The overall risk of bias in the included studies was mixed. Details on random sequence generation, allocation concealment, and use of intention-to-treat analysis were typically poorly reported. Evidence from nine trials (n = 1173) suggested little to no difference in mortality between ExCR and non-exercise controls (risk ratio (RR) 1.06, 95% confidence interval (CI) 0.76 to 1.49; I² = 0%; 101 deaths; low-certainty evidence). Based on evidence from 10 trials (n = 825), ExCR may have little to no effect on SAEs (RR 1.30, 95% CI 0.63 to 2.67; I² = 0%; 28 events; low-certainty evidence). Evidence from four trials (n = 378) showed that ExCR likely reduced AF recurrence (measured via Holter monitoring) compared to controls (RR 0.70, 95% CI 0.56 to 0.88; I² = 2%; moderate-certainty evidence). ExCR may reduce AF symptom severity (mean difference (MD) -1.59, 95% CI -2.98 to -0.20; I² = 61%; n = 600; low-certainty evidence); likely reduces AF symptom burden (MD -1.61, 95% CI -2.76 to -0.45; I² = 0%; n = 317; moderate-certainty evidence); may reduce AF episode frequency (MD -1.29, 95% CI -2.50 to -0.07; I² = 75%; n = 368; low-certainty evidence); and likely reduces AF episode duration (MD -0.58, 95% CI -1.14 to -0.03; I² = 0%; n = 317; moderate-certainty evidence), measured via the AF Severity Scale (AFSS) questionnaire. Moderate-certainty evidence from six trials (n = 504) showed that ExCR likely improved the mental component summary measure in health-related quality of life (HRQoL) of the 36-item Short Form Health Survey (SF-36) (MD 2.66, 95% CI 1.22 to 4.11; I² = 2%), but the effect of ExCR on the physical component summary measure was very uncertain (MD 1.75, 95% CI -0.31 to 3.81; I² = 52%; very low-certainty evidence). ExCR also may improve individual components of HRQoL (general health, vitality, emotional role functioning, and mental health) and exercise capacity (peak oxygen uptake (VO) and 6-minute walk test) following ExCR. The effects of ExCR on serious adverse events and exercise capacity were consistent across different models of ExCR delivery: centre compared to home-based, exercise dose, exercise only compared to comprehensive programmes, and aerobic training alone compared to 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. ExCR likely improves AF-specific measures including reduced AF recurrence, symptom burden, and episode duration, as well as the mental components of HRQoL. ExCR may improve AF symptom severity, episode frequency, and VO. 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.
心房颤动（AF）是最常见的心律失常，通过心房组织中的许多小折返环路扰乱心脏节律，导致不规则的心房收缩。这种情况会带来重大的健康风险，包括增加中风风险、心力衰竭和降低生活质量。鉴于 AF 的复杂性及其在全球范围内的发病率不断上升，基于运动的心脏康复（ExCR）可能为 AF 患者或正在接受常规治疗的患者提供额外的益处。
评估与非运动对照组相比，ExCR 对目前患有 AF 或已接受 AF 治疗的患者的益处和危害。
我们检索了以下电子数据库：Cochrane 图书馆中的 CENTRAL、Ovid 中的 MEDLINE、Ovid 中的 Embase、Ovid 中的 PsycINFO、Thomson Reuters 中的 Web of Science 核心合集、EBSCO 中的 CINAHL、BIREME 中的 LILACS 和两个临床试验注册处，检索日期为 2024 年 3 月 24 日。我们没有设置语言限制。
我们纳入了比较 ExCR 干预与任何类型非运动对照组的随机临床试验（RCT）。我们纳入了 18 岁或以上的任何类型 AF 患者或接受过 AF 治疗的患者。
五名综述作者独立筛选并重复提取数据。我们使用 Cochrane 手册中概述的 RoB 1 工具评估偏倚风险。我们通过观察森林图和使用标准 Chi² 和 I² 统计量来评估临床和统计学异质性。我们使用随机效应模型对连续和二分类结局进行 meta 分析。我们使用不同量表测量相同结局时计算标准化均数差。我们使用 GRADE 方法评估证据的确定性。
我们纳入了 20 项 RCT，共涉及 2039 名 AF 患者。所有试验均在 2006 年至 2024 年之间进行，随访时间从八周至五年不等。我们评估证据的确定性为中度至非常低。五项试验评估了综合性 ExCR 方案，其中包括教育或心理干预，或两者兼而有之；其余 15 项试验比较了仅运动的心脏康复与对照组。纳入研究的整体偏倚风险混杂。关于随机序列生成、分配隐藏和意向治疗分析的详细信息通常报告得很差。来自 9 项试验（n = 1173）的证据表明，ExCR 与非运动对照组相比，死亡率几乎没有差异（风险比（RR）1.06，95%置信区间（CI）0.76 至 1.49；I² = 0%；101 例死亡；低确定性证据）。基于 10 项试验（n = 825）的证据，ExCR 可能对严重不良事件（RR 1.30，95%CI 0.63 至 2.67；I² = 0%；28 例事件；低确定性证据）几乎没有影响。四项试验（n = 378）的证据表明，与对照组相比，ExCR 可能降低 AF 复发（通过动态心电图监测测量）（RR 0.70，95%CI 0.56 至 0.88；I² = 2%；中等确定性证据）。ExCR 可能降低 AF 症状严重程度（MD -1.59，95%CI -2.98 至 -0.20；I² = 61%；n = 600；低确定性证据）；可能降低 AF 症状负担（MD -1.61，95%CI -2.76 至 -0.45；I² = 0%；n = 317；中等确定性证据）；可能降低 AF 发作频率（MD -1.29，95%CI -2.50 至 -0.07；I² = 75%；n = 368；低确定性证据）；并可能降低 AF 发作持续时间（MD -0.58，95%CI -1.14 至 -0.03；I² = 0%；n = 317；中等确定性证据），通过心房颤动严重程度量表（AFSS）问卷测量。来自六项试验（n = 504）的中等确定性证据表明，ExCR 可能改善 36 项简短健康调查（SF-36）的心理健康成分综合测量（MD 2.66，95%CI 1.22 至 4.11；I² = 2%），但 ExCR 对身体成分综合测量的效果非常不确定（MD 1.75，95%CI -0.31 至 3.81；I² = 52%；非常低确定性证据）。ExCR 还可能改善健康相关生活质量（HRQoL）的个别成分（一般健康、活力、情绪角色功能和心理健康）和运动能力（峰值摄氧量（VO）和 6 分钟步行试验）。ExCR 对严重不良事件和运动能力的影响在不同的 ExCR 交付模式中是一致的：中心与家庭为基础、运动剂量、仅运动与综合性方案、以及单纯有氧运动与有氧运动加抗阻运动方案。使用单变量 meta 回归，有证据表明试验地点与最长随访时的运动能力之间存在显著关联。
由于随机参与者人数较少且通常随访时间较短，因此目前尚不确定 ExCR 对 AF 患者的全因死亡率或严重不良事件的影响。ExCR 可能改善 AF 特异性措施，包括降低 AF 复发、症状负担和发作持续时间，以及 HRQoL 的心理成分。ExCR 可能改善 AF 症状严重程度、发作频率和 VO。需要未来开展高质量 RCT 来评估 AF 患者接受 ExCR 治疗后的患者相关结局，包括 AF 症状严重程度和负担、AF 复发、AF 特异性生活质量以及死亡率、再入院和严重不良事件等临床事件。需要高质量的试验来研究 AF 亚型和临床环境（即初级和二级保健）如何影响 ExCR 的有效性。
