Randomised, Controlled Trial of Exercise Training versus Standard Medical Care on Atrial Fibrillation Recurrence After Ablation in Patients with Symptomatic Atrial Fibrillation

Intervention

Intervention code Treatment: Other

This progressive exercise interventions builds on successful interventions implemented in different settings by members of the investigator team. Specifically, the intervention includes four phases: Phase 1 (0-3 wks post-ablation, Recovery) will include a remote education component, delivered using online video consultation, that provides guidance on establishing physical activity following an ablation procedure. During these remote consultations, a clinical exercise physiologist will outline th .... This progressive exercise interventions builds on successful interventions implemented in different settings by members of the investigator team. Specifically, the intervention includes four phases: Phase 1 (0-3 wks post-ablation, Recovery) will include a remote education component, delivered using online video consultation, that provides guidance on establishing physical activity following an ablation procedure. During these remote consultations, a clinical exercise physiologist will outline the evidence-base regarding exercise training for AF patients and will discuss potential barriers to exercise with the patient. The forms of exercise that are suitable for patients with AF will be discussed. The preferences of each patient regarding modes of exercise will be evaluated. Supervised visits will commence from 3 weeks post-ablation. It is anticipated that two 30-minute consultations will be provided within this phase of the intervention. Phase 2 (3-12 wks, Base Training) will target a 10-20% weekly increase in aerobic exercise duration progressing to 210 minutes per week and will include fortnightly supervised visits with an exercise physiologist, with each visit lasting approximately 1 hour. Aerobic exercise will be prescribed within the moderate exercise domain (60-80% heart rate reserve [HRR] or rating of perceived exertion of 6-7 out of 10). Examples of home-based aerobic exercise prescribed within this phase may include outdoor walking, cycling on flat terrain, swimming, dancing or group aerobic exercise. Home-based aerobic exercise will be monitored using a heart rate monitor provided to each patient, and a physical activity diary that can be completed each day. During supervised exercise sessions, participants may be recommended treadmill walking, indoor cycling, rowing, or elliptical exercise, with continuous monitoring using heart rate enabled watches. Attendance at each supervised session will be recorded by study investigators. Phase 3 (12-26 wks, Adaptation) will progressively initiate aerobic interval training activities up to twice per week using a 4x4-min interval structure with a target intensity of 85-90% HRR for each interval. For participants, this means completing four-minute ‘intervals’ at an intensity that requires heavy breathing and an increase in heart rate up to approximately 90% of its maximum, as determined during baseline testing. Participants will repeat these intervals four times, with a three-minute active recovery between each effort. Active recovery may include slow walking or light cycling. Home-based aerobic interval training may be performed on a grass sports pitch, walking trail or hilly area. Supervised visits will remain on a fortnightly frequency. During supervised visits, aerobic interval exercise will be performed on an indoor bike or treadmill. Through phase 3, the target weekly aerobic exercise duration will remain at 210 minutes of moderate to vigorous activity. Attendance at each supervised session will be recorded by study investigators. Finally, in Phase 4 (26-52 wks, Maintenance) will focus on maintenance of aerobic exercise habits, whilst ensuring appropriate progression in intensity in proportion to adaptation of individual physical capacity. During phase 4, supervised visits of 45-60 minutes will decrease in frequency to monthly. However, scheduled televisits of 15-30 minutes will be planned with a clinical exercise physiologist during the intervening periods to promote adherence and modify/update exercise prescription where required. Throughout the intervention phase, all home-based aerobic exercise will be recorded using commercially available heart rate monitors and physical activity trackers provided to each patient. Tailored, individualised exercise plans will be provided to each patient after completion of each supervised visit. Adherence to the intervention will be assessed through documented exercise recorded on heart rate monitors and attendance records for supervised visits maintain by study staff.
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Comparison

Control group Active

Patients in the control arm (standard medical care only) will continue to receive guideline-directed, standard medical care as per current National Heart Foundation/Cardiac Society of Australia and New Zealand clinical guidelines. Principally, this focusses on three pillars of AF management (rate & rhythm control, anticoagulation). In our centre, this includes nurse and physician-led management of AF risk factors. Within this framework, participants in the control arm will attend quarterly consu .... Patients in the control arm (standard medical care only) will continue to receive guideline-directed, standard medical care as per current National Heart Foundation/Cardiac Society of Australia and New Zealand clinical guidelines. Principally, this focusses on three pillars of AF management (rate & rhythm control, anticoagulation). In our centre, this includes nurse and physician-led management of AF risk factors. Within this framework, participants in the control arm will attend quarterly consultations of 30-45 minutes with a clinical exercise physiologist to discuss and promote recommended physical activity targets (150 minutes moderate physical activity per week), specific to their condition. Control group sessions will be offered over a 12-month period in parallel with the duration of the intervention arm.
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Outcomes

Outcome: Recurrence of any atrial fibrillation over 30s in duration, detected by implantable loop recorder, routine Holter monitoring or 12-lead electrocardiography.
Timepoint: 18-month follow-up from date of AF ablation, excluding 3-month blanking period immediately following AF ablation.