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The 2020 Canadian Cardiovascular Society (CCS) guidelines for the management of atrial fibrillation (AF) are the first in the world to provide specific exercise targets (aerobic exercise: ≥ 200 minutes per week of moderate intensity; resistance: 2 to 3 days per week; flexibility: ≥ 10 minutes per day at least 2 days per week in those ≥ 65 years of age).
Although we commend the authors for their inclusion, there are several key points that merit further discussion.
Recent reviews of exercise-based cardiac rehabilitation (CR) in patients with AF have shown improvements in exercise tolerance and poor quality of life (Fig. 1).
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
This evidence is limited, however, given the few studies and the heterogeneity of their interventions, which is perhaps why the guidelines did not discuss these reviews or include referral to CR as an element of AF management. Greater exercise levels and cardiorespiratory fitness (CRF)—well-established outcomes of CR—are associated with lower long-term risk of cardiovascular disease and all-cause mortality in patients with AF.
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
but a discussion of the specific “dose-related” effects of exercise were lacking. We presume the ≥ 200 minutes per week of moderate-intensity exercise prescribed in these observational studies led by Pathak and colleagues was used to establish the exercise targets in the guidelines,
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
The guidelines also include resistance and flexibility targets, yet most of the exercise interventions in patients with AF have either not included resistance training or tested different paradigms (ie, inspiratory muscle training, yoga).
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
The effectiveness of these targets specific to AF outcomes remains to be investigated and is currently unknown; this should be acknowledged.
The guidelines described notable clinical sex differences yet not those identified in the exercise and AF literature. Nearly 20 years elapsed between the first and second exercise-based intervention in patients with AF reporting sex-specific outcomes (Fig. 1).
The lack of sex-based analyses and female under-representation in exercise research (eg, exercise-based studies in patients with AF include ∼25% female participants)
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
results in women often being recommended treatment options without empirical support; this merits acknowledgement.
In summary, the guidelines fall short in their justification of the aerobic exercise volume and intensity, resistance training and flexibility targets, and reflection of the growing literature regarding the role of exercise-based CR in addressing the needs of patients with AF. Patients with AF have highlighted the need for clear advice and support from health care professionals following diagnosis and treatment of AF, particularly as it relates to exercise. Our suggestions for future research are provided herein (Fig. 1).
Funding Sources
Dr Terada was supported by the Jan & Ian Craig Cardiac Prevention and Rehabilitation Endowed Fellowship from the University of Ottawa Heart Institute and a Canadian Institutes of Health Research (CIHR) Postdoctoral Fellowship. Sol Vidal-Almela was supported by the Philanthropic Educational Organization (PEO), with an International Peace Scholarship.
Disclosures
The authors have no conflicts of interest to disclose.
References
Andrade JG
Aguilar M
Atzema C
et al.
The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation.
Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials.
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review.
We thank Dr Reed and colleagues for their letter. A major focus of the comprehensive 2020 atrial fibrillation (AF) guidelines was to emphasise that AF should not be considered an isolated heart-rhythm disorder. A key pillar of this holistic approach to management of AF is aggressive risk-factor modification. It is well known that higher levels cardiorespiratory fitness are associated with an improved cardiovascular risk-factor profile and a reduction in all-cause mortality and cardiovascular events.
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