Patient education and physical training for patients with AF
programme can improve QoL and physical exercise
capacity in patients with AF and, potentially, prevent
readmissions.
Objective
The aim of this study was to investigate whether a
rehabilitation programme with group education, phy-
sical exercise, optimization of medical treatment and
monitoring of lifestyle changes can improve QoL and
physical exercise capacity in patients with AF.
METHODS
Design
Clinical randomized controlled trial. ClinicalTrials.gov (record
N-20120002).
Patients
Patients with paroxysmal or persistent AF admitted to the De-
partment of Cardiology, Aalborg University Hospital between
6 June 2012 and 4 April 2013 were consecutively invited to
participate in the study. All patients received treatment according
to the current guidelines . Patients who provided informed
consent to participate were randomized to either specialized
cardiac rehabilitation or standard follow-up. The rehabilitation
programme consisted of groups of 10 patients.
At the primary admission, all patients underwent echocardio-
graphy and blood samples were taken.
Inclusion criteria. Patients ≥ 18 years of age, hospitalized at the
Department of Cardiology, Aalborg University Hospital, with
a diagnosis of paroxysmal or persistent AF documented by an
electrocardiogram (ECG) or > 30 s of AF recorded by long-term
monitoring. All participants received oral and written informa-
tion prior to providing written informed consent.
Exclusion criteria. atients who qualified for cardiac rehabilita-
tion due to other cardiac conditions (congestive heart failure or
CHD) were excluded. If AF was caused by a reversible condition
patients were also excluded.
Heart failure (New York Heart Association (NYHA) class
III–IV or Left Ventricular Ejection Fraction (LVEF) < 40%) or
valvular heart disease and patients admitted for radiofrequency
ablation were also excluded. Patients considered too ill, phy-
sically or mentally, to participate in rehabilitation by the treating
physicians were excluded.
Randomization
Randomization was electronically, randomizing the participants
into 2 groups of 20 participants at a time.
Rehabilitation
The rehabilitation programme included education, physical
exercise, optimization of the medical treatment and discussion
of implications on daily life.
The group sessions with a doctor, a nurse, a dietician or a psy-
chologist was scheduled once a week for 1 h for the first 8 weeks.
The education included information on pathophysiology, risk
factors, treatment, diet and coping mechanisms for living with AF.
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The exercise programme was conducted as 1-h sessions twice
a week for 12 weeks and supervised by a cardiac rehabilitation
physiotherapist. Each training session consisted of at least 30
min of aerobics ≥ 70% of maximum exercise capacity estimated
from a maximum cycle ergometer test with ECG monitoring
and graded on the Borg scale (score 14–16) and interval training
with elements of strengthening exercises (13).
Patients were encouraged to be moderately physically active
≥ 30 min each day and, if they missed a group training session,
to perform 30 min of high-intensity activities.
Medication
The medical treatment was optimized according to the current
guidelines.
Quality of life
At inclusion and after 3, 6 and 12 months, all participants
completed the following disease-specific QoL questionnaires:
Health-related Quality of Life in patients with Atrial Fibrilla-
tion (AF-QoL-18) and Atrial Fibrillation Effect on QualiTy of
Life (AFEQT) and the generic QoL questionnaires: Generalised
Anxiety Disorder Assessment (GAD-7), Patient Health Ques-
tionnaire (PHQ-9) and EuroQol 5D (EQ-5D).
AF-QoL-18 includes 18 questions on 3 domains: psychologi-
cal, physical and sexual activity. The answer score range from
zero (worst) to 100 (best). AFEQT includes 20 questions on
treatment, symptoms and daily activity during the last 4 weeks.
The score range from 20 (best) to 140 (worst).
GAD-9 assesses anxiety and results range from zero (worst)
to 21 (best). PHQ-9 focuses on depression symptoms during the
latest 2 weeks ranging from zero (best) to 27 (worst). EQ-5D
consists of 5 questions on mobility, self-care, usual activities,
pain/discomfort, anxiety/depression and a visual analogue scale
(EQVAS) assessing self-estimated health status.
Physical exercise tests
At inclusion and after 3 and 6 months, all participants were
tested by an ergometer cycle test, a 6-min walk (6MW) test
and a 5-repetition-sit-to-stand (5RSS) test .
The ergometer cycle test was performed in accordance with
the standard for exercise testing of the American Heart Associa-
tion (14). The maximal physical capacity test was used as an
indirect measure of the maximum exercise capacity. Participants
started at 50 Watt (W), with a 25-W load increase for each 2
min until the participants could no longer maintain a speed of
60 rotations/min due to fatigue/dyspnoea.
The 6MW test is a simple, safe and inexpensive test to estima-
te submaximum exercise capacity. The test results correlate well
with functional capacity and can be used prognostically (15).
The 5RSS test is also a simple, safe and inexpensive test
evaluating the strength of the lower extremities by the patient
standing up from a sitting position as quickly as possible 5
times in a row (16).
All tests were performed by one of 2 trained physiotherapists,
who were blinded to whether the participant participated in
rehabilitation.
Statistical analysis
Quality of life. From the study by Arribas et al. in 2010 (17),
mean and standard deviation (SD) of AF-QoL-18 in a population
of Spanish patients with AF were stated to be: mean 38.9 and
J Rehabil Med 51, 2019