448
A. M. Joensen et al.
4). There was no statistically significant difference
between groups.
DISCUSSION
This study found that a full rehabilitation programme
including group education and physical training for
patients with paroxysmal or persistent AF was bene-
ficial, with statistically significant improvement of
QoL measured with both disease-specific (AF-QoL-18,
AFEQT) and non-disease-specific (GAD-7, PHQ-9,
EQ-5D) questionnaires during the first 6 months, after
which the effect attenuated.
Five different questionnaires were used to assess
different aspects of QoL. In all questionnaires, there
was an increase in QoL for all participants from the
start to the end of the study, which was consistent with
results from other studies (19, 20). The intervention
group experienced a higher increase in QoL during the
first 6 months (although not statistically significant in
all questionnaires) and a subsequent attenuation of the
intervention effect compared with the control group.
An earlier study regarding the AFEQT questionnaire
suggested that a mean change of approximately 12
points was correlated with a small improvement and
< 5.3 points was an unimportant improvement (21). Our
study showed a difference of 7.6 points after 3 months,
potentially suggesting a small clinical importance.
In addition, a positive effect was found on maximum
O 2 uptake, whereas no convincing improvement was
found in the other physical tests.
At baseline, there was a statistically significant
difference between the intervention and the control
group in the performance of the physical tests despite
randomization. However, this did not have any statis-
tically significant effect on the results, as stratification
by O 2 uptake at baseline did not show a different effect
of training in patients with a low O 2 uptake compared
with those with a high uptake.
Physical exercise has been shown to reduce the risk
and magnitude of, for example, hypertension, diabetes
mellitus and obesity, and has been shown to be benefi-
cial for patients with CHD and congestive heart failure
(22, 23). Thus, physical exercise may potentially lead
to a reduction in the risk of developing AF. However,
long duration of vigorous training may increase the risk
of developing AF (8), although it seems that moderate
physical exercise have a protective effect on patients
with permanent AF (8, 24). Regarding physical exer-
cise and non-permanent AF, Malmo et al. (25) found
that aerobic interval training reduced the time in AF
and improved QoL estimated from the Short Form-
www.medicaljournals.se/jrm
36 (SF-36) questionnaire. Furthermore, training also
significantly improved AF symptoms, VO 2 peak, left
atrial and ventricular function.
Risom et al. (26) conducted a 12-week randomized
trial on rehabilitation for patients with paroxysmal or
persistent AF after catheter ablation. The authors found
an improved physical capacity assessed by VO 2 peak,
which is in line with our results. The authors did not
find a statistically significant improvement in the 6MW
test in the training group compared with the control
group, which was comparable with our results. They
did not find an improvement of the mental health based
on a non-disease specific questionnaire. As radiofre-
quency ablation was an exclusion criterion in our study
the results cannot be directly compared.
Skielboe et al. included 76 patients with paroxysmal
or persistent AF who were randomized to high- or
low-intensity exercise for 12 weeks. Both groups im-
proved their peak VO 2 significantly (11). QoL was not
measured. Recent studies have compared AF patients
and non-AF patients who joined a cardiac rehabilita-
tion programme for other cardiovascular diseases or
cardiovascular risk factors. Younis et al. found that
patients with AF initially had lower physical capacity
than non-AF participants, but improvement in physical
capacity diminished the risk of total mortality and car-
diovascular hospitalization for both groups (27). In a
case control study Reed et al. found that rehabilitation
improved QoL in both groups, but to a greater extent
in patients without AF (28).
Although patients with paroxysmal AF may be in si-
nus rhythm most of the time, they may be less likely to
be physically active because of anxiety about initiating
AF (29). Even when patients were in sinus rhythm, this
study showed that QoL and physical capacity could be
improved. We also found an improvement of the 6MW
test in the control group, perhaps because participating
in the study encouraged patients to be more physically
active even though they were in the control group. The
bicycle tests favoured the intervention group, proba-
bly because bicycle training was a central part of the
physical exercise programme.
Establishing whether physical exercise in patients
with AF would be beneficial to reduce the risk of co-
morbidities and the burden of AF will require larger
studies with longer follow-up.
The rehabilitation programme seemed to have the
highest impact on reducing anxiety and depression
and increasing physical and psychological well-being
(estimated by questionnaires with focus on these
domains: AF-QoL-18, GAD-7 and PHQ-9) and al-
leviating patients’ symptoms (as assessed by AFEQT).