A new meta-analysis lends support to the idea, but researchers caution many specifics must still be worked out.
Patients with atrial fibrillation (AF) gain clinical benefit from exercise-based cardiac rehabilitation without experiencing a rise in serious adverse events, according to a contemporary look at the evidence base.
The review and meta-analysis, published July 29, 2025, in the British Journal of Sports Medicine, highlights what these interventions stand to offer: lower risk of AF recurrence, better exercise capacity, and AF episodes that are fewer, shorter, and less severe. Patients also seem to derive better mental well-being, the study authors say.
“Although current medical treatments are effective in controlling symptoms and the risk of stroke in AF, the addition of patient self-management interventions are potentially key to the management of arrhythmia progression, maintaining functional capacity and health-related quality of life,” Benjamin J.R. Buckley, PhD (Liverpool John Moores University, England), and colleagues write.
Exercise-based cardiac rehab, they note, involves not only exercise training but also “personalized lifestyle risk factor management, psychosocial intervention, medical risk management, and health behavior education.”
Importantly, while cardiac rehabilitation is endorsed by current guidelines—though sorely underused—in patients with MI, heart failure, and CABG, there is far less evidence for its use specifically in AF patients. This assessment of existing data “is needed,” Buckley told TCTMD, because “we know that exercise can be beneficial for atrial fibrillation,” both in primary prevention and increasingly in secondary prevention.
The paper is a follow-up to a 2017 Cochrane review, by the same research group, that was hindered by the then-small numbers of patients and outcomes. “It was very much inconclusive. We knew there’d been some trials since then, so we wanted to see if that impacted our [prior] conclusion,” he said. The most valuable update in the latest review, he continued, “is it quite positively showed AF-specific improvements, . . . which I think is really powerful.”
No Impact on Mortality or Adverse Events
The researchers combined data from 20 randomized controlled trials, which included 2,039 patients (mean age 63 years; 73% men) and a mean follow-up of 11 months. All compared exercise-based cardiac rehab against control arms that did not involve exercise but instead consisted of education, psychological intervention, and/or usual medical care. Ten were conducted in Europe, four in Asia, two in Australia, and one each in Brazil, Canada, Russia, and multiple countries.
Cardiac rehab had no impact on all-cause mortality (8.3% vs 6.0%; RR 1.06; 95% CI 0.76-1.48) or serious adverse events (2.9% vs 4.1%, RR 1.30; 95% CI 0.66-2.56). However, its use was associated with lower risk of AF recurrence (RR 0.68; 95% CI 0.53-0.89) and better exercise capacity as measured by VO2 peak (mean difference 3.18; 95% CI 1.05-5.31 mL/kg/min).
Other positive changes occurred in terms of AF symptom severity, AF burden, episode frequency, and episode duration. For health-related quality of life, there was benefit for the mental but not the physical component of the SF-36.
The results did not differ by either the dose/delivery mode of exercise-based cardiac rehab or the specific subtype of AF.
“Various mechanisms have been proposed for how exercise-based interventions can lead to improvement in AF participant outcomes,” the study authors note. “While improvements in traditional cardiovascular risk factors likely account for a substantial proportion of the benefit, additional mechanisms may directly impact AF burden and recurrence.”
For example, evidence suggests exercise training promotes favorable atrial remodeling. The moderate-intensity physical activity that’s included in these programs also “may optimize autonomic balance, preserving heart rate variability and parasympathetic benefits,” they write. “Additionally, exercise induced improvements in vascular function and hemodynamics, including enhanced endothelial function, arterial compliance and left atrial hemodynamics, may reduce AF morbidity by improving overall cardiovascular efficiency.”
Also important, Buckley et al note, are the psychological benefits of exercise that can ease the anxiety and depression that often accompany heart disease.
‘Tailored, Progressive’ Approach Needed
Sarandeep Marwaha, MBBS, and Sanjay Sharma, MD (both from City St George’s, University of London, England), in an editorial, agree physical activity is likely to help patients with AF.
“Exercise is widely recognized as an important management tool, and it is crucial to highlight that it remains one of the most cost-effective, readily available, and manageable interventions for improving cardiovascular health,” they note, adding that the new study “reinforces the invaluable role that physical activity plays in managing AF. By prioritizing exercise, healthcare providers can offer an accessible strategy for improving outcomes.”
Yet precisely what goes into rehab programs does matter, they caution.
“Exercise prescription for patients with AF should be tailored to their health status, fitness, and desired activities,” with an emphasis on moderation, Marwaha and Sharma advise. “In general, new exercise programs should begin slowly with a gradual increase to achieve guideline-recommended volumes of physical activity.”
Start small. We wouldn’t expect someone who does very little activity to jump to 150 minutes per week or 300 minutes per week, because that’s just asking for trouble. Benjamin J.R. Buckley
Buckley agreed that there are details to be worked out. Among the barriers are the lack of capacity and added cost of extending cardiac rehab to a new population. The Liverpool-based investigators are exploring ways to surmount those challenges.
First, there’s the question of whether it’s possible to fit people with AF into programs already delivering rehab to patients with heart failure or after MI, he said. “Do [patients] like it? Are the practitioners happy to deliver it? Are there any fears from a patient and a clinician level?” The team also intends to take a deeper dive into the trial data to see if there are differences related to sex, age, comorbidities, or AF type that might affect rehab’s impact. And finally, there may be a role for telehealth, he added. “How can we use technology from a remote perspective to monitor AF symptoms and also try and change behavior?”
That said, at least based on the current knowledge base, “it didn’t really seem to matter what intervention they received,” he pointed out. “As long as they received a type of cardiac rehab, there was a benefit, so it may be the case that something is better than nothing.”
This comes with “the caveat that [interventions] should be personalized,” said Buckley, adding that as with any cardiovascular condition, high-risk patients should speak with their clinician before ramping up physical activity. “Start small. We wouldn’t expect someone who does very little activity to jump to 150 minutes per week or 300 minutes per week, because that’s just asking for trouble.”
Instead, these cases warrant “a tailored, progressive program, . . . where we try and change one or two things within their lifestyle initially and then build from that,” he said.