Exercise Cuts Arrhythmia Burden by 45% in AF

MUNICH — In patients with symptomatic paroxysmal or persistent atrial fibrillation (AF), a personalized long-term physical activity program reduced arrhythmia burden by 45% at 1 year compared with standard care, according to results from the multicenter randomized NEXAF trial presented at the European Society of Cardiology (ESC) Congress 2026.The trial, which enrolled nearly 300 patients, adds to growing evidence supporting exercise in AF — an intervention that remains underused despite guideline recommendations. The first European guidelines on cardiac rehabilitation, also presented at ESC 2026, highlighted the value of this approach in patients with AF (see box).“According to a survey by the European Heart Rhythm Association, only one in ten eligible patients [with AF] is referred to an exercise-based rehabilitation program,” said principal investigator Bjarne Nes, PhD, of the Norwegian University of Science and Technology in Trondheim, Norway, who noted “a gap in guideline implementation.”Fewer AF Hospitalizations“Patients, as well as clinicians, are often concerned that physical activity may worsen AF,” Nes said during his presentation. However, available evidence suggests a J-shaped relationship, with arrhythmia risk increasing beyond 300 minutes of moderate-intensity activity or 150 minutes of vigorous-intensity activity per week.In the randomized trial, which compared an individualized physical activity program with standard care, “a 1-year exercise-based intervention resulted in a significant reduction in overall AF burden, improved physical fitness, and fewer AF-related hospitalizations,” Nes said.The intervention consisted of eight supervised high-intensity sessions during the first 4-6 weeks, followed by remote monitoring and support aimed at maintaining at least 175 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week.Guidelines Endorse Structured ExerciseHigh blood pressure, overweight and obesity, sleep apnea, alcohol consumption, and physical inactivity are among the modifiable risk factors for AF that should be addressed in both primary and secondary prevention. Since the 2024 ESC guidelines for the management of AF, a structured exercise program has been recommended for consideration as part of secondary prevention to reduce recurrence risk.The first European guidelines on cardiac rehabilitation, unveiled at ESC 2026, also endorse medically supervised exercise training as part of rehabilitation for patients with AF. This approach is intended to “reduce the severity of AF-related symptoms, symptom burden, the frequency and duration of episodes, as well as recurrences,” the document states.Although the benefits of physical activity in AF are now well recognized, prior trials have generally been small and of short duration, Nes noted. NEXAF trial was designed to assess the effects of a 1-year intervention on time spent in AF, rather than simply recurrence, which he said distinguishes the trial.The trial was conducted at three centers in Norway and included 295 patients (mean age, 64 years; 30% women) with symptomatic paroxysmal AF — characterized by intermittent episodes lasting fewer than 7 days — or persistent AF, diagnosed on average 5 years earlier. Patients with permanent AF and those who had recently undergone ablation or were scheduled for ablation were excluded.Remote MonitoringPatients were randomized either to the physical activity program for 1 year or to standard care, which did not include a structured exercise intervention. The program included remote monitoring through a smartwatch, an app, and an online platform. All patients also received an implantable cardiac monitor.The two primary endpoints were time spent in AF during the 1-year follow-up period and change in quality of life at 1 year, assessed with the AF Effect on Quality-of-Life (AFEQT) questionnaire.At 1 year, time spent in AF was 45% lower in the physical activity group than in the control group (3.9% vs 7.1% of follow-up time). However, this improvement was not accompanied by a significant between-group difference in quality of life as measured by the AFEQT score (+5.6 vs +4.4 points).Among the secondary endpoints, the exercise intervention improved cardiorespiratory fitness and resting heart rate. Investigators also reported a 37% reduction in total hospitalizations and a 46% reduction in AF-related hospitalizations.Determining Dose and IntensityAccording to Nes, this hybrid model — combining short-term in-clinic supervision with a long-term home-based exercise program supported by digital tools — required limited personnel and appeared feasible in routine practice.“This trial strengthens the case for broader implementation of structured, long-term physical exercise in the management of AF,” he concluded.Asked to comment on the findings, Elena Arbelo, MD, PhD, of Hospital Clínic de Barcelona in Barcelona, Spain, said this preventive strategy now needs to be better defined “by determining the dose and intensity of exercise required” to ensure both clinical benefit and adherence to the program.According to Arbelo, it will also be important “to better identify which patients will benefit from this type of intervention” and to continue follow-up to determine whether the approach can be sustained over the long term.This story was translated from Medscape’s French edition.