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Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation

Open AccessPublished:August 16, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.07.010
      Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.
      Atrial fibrillation (AF) has been recognized as a major risk factor for ischemic stroke
      • Ball J
      • Carrington MJ
      • McMurray JJ
      • Stewart S.
      Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century.
      ,
      • Samol A
      • Masin M
      • Gellner R
      • Otte B
      • Pavenstädt HJ
      • Ringelstein EB
      • Reinecke H
      • Waltenberger J
      • Kirchhof P.
      Prevalence of unknown atrial fibrillation in patients with risk factors.
      and contributes to the development of heart failure, myocardial infarction, and all-cause mortality.
      • Staerk L
      • Sherer JA
      • Ko D
      • Benjamin EJ
      • Helm RH.
      Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes.
      Exercise has been shown to modify several risk factors that contribute to the development of AF, including reducing body weight, blood pressure, and serum low-density lipoprotein levels.
      • Myers J.
      Cardiology patient pages. Exercise and cardiovascular health.
      Current guidelines recommended at least 150 minutes per week of moderate-intensity physical activity (PA), which also translates as 500 metabolic equivalent task (MET) minutes per week of PA. However, it remains unclear whether the same level of PA would benefit the AF population.
      • Bosomworth NJ.
      Atrial fibrillation and physical activity: should we exercise caution?.
      Using data collected from a large prospective study,
      • McManus DD
      • Kiefe C
      • Lessard D
      • Waring ME
      • Parish D
      • Awad HH
      • Marino F
      • Helm R
      • Sogade F
      • Goldberg R
      • Hayward R
      • Gurwitz J
      • Wang W
      • Mailhot T
      • Barton B
      • Saczynski J.
      Geriatric conditions and prescription of vitamin K antagonists vs. direct oral anticoagulants among older patients with atrial fibrillation: SAGE-AF.
      we examined the association between guideline-recommended level of PA and major adverse clinical outcomes, including total mortality, stroke, major bleeding, and clinically relevant bleeding in older adults with AF.

      Methods

      We used data collected in the Systematic Assessment of Geriatric Elements (SAGE)-AF study to perform a retrospective study. SAGE-AF is a prospective study of AF, oral anticoagulation treatment, and relations between comprehensive baseline geriatric assessment. The study started on February 17, 2016 and ended on January 31, 2020.
      • McManus DD
      • Kiefe C
      • Lessard D
      • Waring ME
      • Parish D
      • Awad HH
      • Marino F
      • Helm R
      • Sogade F
      • Goldberg R
      • Hayward R
      • Gurwitz J
      • Wang W
      • Mailhot T
      • Barton B
      • Saczynski J.
      Geriatric conditions and prescription of vitamin K antagonists vs. direct oral anticoagulants among older patients with atrial fibrillation: SAGE-AF.
      Eligible study participants included those who were scheduled for an ambulatory care visit at 1 of 4 Central Massachusetts practices (University of Massachusetts Memorial Health Care internal medicine, cardiology, or electrophysiology, Heart Rhythm Associates of Central Massachusetts), 1 practice in Eastern Massachusetts (Boston University cardiology), or 1 of 2 practices in Central Georgia (Family Health Center and Georgia Arrhythmia Consultants); and participants with AF (if the arrhythmia was present on an electrocardiogram or Holter monitor or if it was noted in any clinic note or hospital record), who were aged ≥65 years and had a congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, age 65 to 75 and sex (CHA2DS2-VASc score) ≥2.
      • Lip GY
      • Nieuwlaat R
      • Pisters R
      • Lane DA
      • Crijns HJ.
      Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
      Participants who were not eligible for enrollment were those who had documentation of an absolute contraindication to anticoagulation or had an indication for anticoagulation other than AF, were unable to provide signed informed consent, did not speak English, had a planned invasive procedure with high risk for uncontrolled bleeding, or were unwilling or unable to participate in planned 1- and 2-year follow-up visits at their study sites.
      • Saczynski JS
      • Sanghai SR
      • Kiefe CI
      • Lessard D
      • Marino F
      • Waring ME
      • Parish D
      • Helm R
      • Sogade F
      • Goldberg R
      • Gurwitz J
      • Wang W
      • Mailhot T
      • Bamgbade B
      • Barton B
      • McManus DD.
      Geriatric elements and oral anticoagulant prescribing in older atrial fibrillation patients: SAGE-AF.
      The study protocol was approved by the University of Massachusetts Medical School, Boston University, and Mercer University Institutional Review Boards.
      Participants’ baseline characteristics, including their demographics (i.e., age, gender, race, level of education, marital status), clinical characteristics (i.e., body mass index [BMI], type of AF, time since AF diagnosis, CHA2DS2-VASc score, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition labile international normalized ratio, elderly, drugs/alcohol concomitantly (HAS-BLED) score, previously diagnosed chronic obstructive pulmonary disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease and stroke, and smoking status were abstracted from hospital and clinic medical records by trained research staff. Geriatric components, including frailty and symptoms of depression, were measured using the Cardiovascular Health Survey frailty scale,
      • Fried LP
      • Tangen CM
      • Walston J
      • Newman AB
      • Hirsch C
      • Gottdiener J
      • Seeman T
      • Tracy R
      • Kop WJ
      • Burke G
      • McBurnie MA
      Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype.
      and Patient Health Questionnaire PHQ-9,
      • Kroenke K
      • Spitzer RL
      • Williams JB.
      The PHQ-9: validity of a brief depression severity measure.
      respectively.
      PA was measured using the Minnesota Leisure Time PA questionnaire at baseline. Participants were asked to report if they performed any of the following activities during the previous 2 weeks: (1) walking at a usual speed for exercise, (2) moderately strenuous household or outdoor chores, (3) indoor activity like dancing or bowling, or (4) any regular activity other than walking. These activities were documented as frequency and duration (in minutes) of each activity participants spent doing. Each type of PA was assigned a MET score based on previously validated energy cost.
      • Ainsworth BE
      • Haskell WL
      • Whitt MC
      • Irwin ML
      • Swartz AM
      • Strath SJ
      • O'Brien WL
      • Bassett Jr, DR
      • Schmitz KH
      • Emplaincourt PO
      • Jacobs DR
      • Jr Leon AS
      Compendium of physical activities: an update of activity codes and MET intensities.
      We calculated and combined the MET-minutes per week task on a weekly basis. The total number of MET-minutes per week was then categorized as a binary variable (yes/no) for engaging in at least 500 MET-minutes per week, which is the recommended level of PA based on current guidelines.
      • Piercy KL
      • Troiano RP
      • Ballard RM
      • Carlson SA
      • Fulton JE
      • Galuska DA
      • George SM
      • Olson RD.
      The physical activity guidelines for Americans.
      Deaths and bleeding events among study participants from hospital medical records and death certificates were adjudicated by a committee of physicians.
      Information on the development of bleeding and stroke events was obtained from the review of hospital medical records. The International Society of Thrombosis and Hemostasis scale was used to grade bleeding events.
      • Schulman S
      • Kearon C
      Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.
      Major bleeding was defined as any fatal bleeding, symptomatic bleeding in a critical area or organ, or bleeding that resulted in a decrease in hemoglobin of 2 g/100 ml, which led to ≥2 units of transfusion.
      • Schulman S
      • Kearon C
      Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.
      ,
      • Wang W
      • Lessard D
      • Saczynski JS
      • Goldberg RJ
      • Mehawej J
      • Gracia E
      • McManus DD.
      Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation.
      Clinically relevant bleeding refers to bleeding events that meet the criteria for a major bleeding episode and all cases of bleeding that did not meet our major criteria but involved temporary interruption of anticoagulation, pain (e.g., hematoma), medical intervention (e.g., macroscopic hematuria), an unscheduled contact (visit or telephone) with a physician, or impairment of daily activities (e.g., inability to walk because of a hematoma).
      • Wang W
      • Lessard D
      • Saczynski JS
      • Goldberg RJ
      • Mehawej J
      • Gracia E
      • McManus DD.
      Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation.
      Baseline sociodemographic, clinical, and psychosocial characteristics of participants who met versus those who did not meet the recommended level of PA were compared using Wilcoxon test for continuous variables and chi-square tests for categoric variables. Charlson co-morbidity score was calculated based on the weight of each co-morbidity.
      The Fine and Gray competing risk models were used to determine if meeting the recommended level of PA was associated with the 4 clinical outcomes examined while controlling for several potentially confounding variables. Variables included in the models were based on their clinical relevance and their level of significance (p <0.05). We adjusted for demographic variables, including age, gender, race, marital status, and education, and clinical co-morbidities, including type of AF, BMI, medical history of chronic obstructive pulmonary disease, coronary artery disease, diabetes, heart failure, hypertension, myocardial infarction, peripheral vascular disease, renal disease, stroke, and symptoms of depression. All statistical analyses were conducted using SAS v 9.4 (SAS Institute Inc., Cary, North Carolina).

      Results

      A total of 1,244 participants were included in the present study. The average age of study participants was 76 years old, 51.2% were men, and the average BMI of the study population was 30.1 kg/m2. Approximately, 60.0% (n = 741) of participants had paroxysmal AF. The average CHA2DS2-VASc score was 4.4 and the average Charlson co-morbidity score was 6. Half (n = 616) of study participants failed to meet the recommended level of PA. After 2 years of follow-up, 108 participants (8.7%) had died, 19 developed stroke (1.5%), 105 had experienced an episode of major bleeding (8.4%), and 382 had an episode of clinically relevant bleeding (30.7%).
      Participants who met the recommended level of PA were younger (74 [69 to 79] vs 76 [71 to 82], p <0.001), had lower BMI (BMI: 28.7 [25.7 to 33.0] vs 29.7 [25.8 to 34.1], p = 0.034), more likely to be men (55.1% vs 47.2%), non-Hispanic White (87.6% vs 82.3%), were married (62.2% vs 51.1%), had a college degree or higher (50.0% vs 36.3%), and had experienced paroxysmal AF (62.1% vs 57.0%) than those who did not meet the recommended level of PA (Table 1).
      Table 1Characteristics of older adults with atrial fibrillation
      VariablesMET recommended level of physical activityp Value
      Yes (n = 628)No (n = 616)
      Age (median (lower, upper quartile))74 (69,79)76 (71,82)<0.001
      Men346 (55.1%)291 (47.2%)0.006
      BMI (median (lower, upper quartile)) (kg/m2)28.7 (25.7, 33.0)29.7 (25.8, 34.1)0.034
      Non-Hispanic white549 (87.6%)507 (82.3%)0.010
      Married384 (62.2%)310 (51.1%)<0.001
      College graduate or higher308 (50.0%)219 (36.3%)<0.001
      Type of AF0.044
       Paroxysmal390 (62.1%)351 (57.0%)
       Persistent153 (24.4%)156 (25.3%)
       Permanent26 (4.1%)47 (7.6%)
      Time Since AF diagnosis (years) (median (lower/upper quartile))4.6 (1.7, 8.2)4.8 (1.9, 8.2)0.433
      Charlson co-morbidity index (median (lower/upper quartile))5 (4, 7)6 (5, 8)<0.001
      Chads2Vasc score (median (lower/upper quartile))4 (3, 5)5 (3, 6)<0.001
      HAS-BLED score (median (lower/upper quartile))3 (2, 4)3 (3, 4)0.003
      Chronic lung disease141 (22.5%)175 (28.4%)0.016
      Coronary artery disease150 (23.9%)198 (32.1%)0.001
      Diabetes mellitus151 (24.0%)195 (31.7%)0.003
      Heart failure182 (29.0%)281 (45.6%)<0.001
      Hypertension554 (88.2%)568 (92.2%)0.018
      Myocardial infarction102 (16.2%)140 (22.7%)0.004
      Peripheral vascular disease76 (12.1%)103 (16.7%)0.020
      Kidney disease139 (22.1%)217 (35.2%)<0.001
      Stroke50 (8.0%)72 (11.7%)0.027
      Anticoagulation use538 (85.7%)526 (85.4%)0.110
      Symptoms of depression136 (21.7%)217 (35.2%)<0.001
      Smoking Status0.303
       Never312 (49.7%)282 (45.8%)
       Former301 (47.9%)314 (51.0%)
       Current15 (2.4%)20 (3.3%)
      Provider type0.060
       Internist21 (3.3%)9 (1.5%)
       Cardiologist301 (47.9%)286 (46.4%)
       Electrophysiologist306 (48.7%)321 (52.1%)
      AF = atrial fibrillation; BMI = body mass index.
      Regarding the clinical co-morbidities, participants in the group who met the recommended PA level were less likely to have to have chronic lung disease (22.5% vs 28.4%), coronary artery disease (23.9% vs 32.1%), diabetes mellitus (24.0% vs 31.7%), heart failure (29.0% vs 45.6%), hypertension (88.2% vs 92.2%), myocardial infarction (16.2% vs 22.7%), peripheral vascular disease (12.1% vs 16.7%), kidney disease (22.1% vs 35.2%), stroke (8.0% vs 11.7%), and symptoms of depression (21.7% vs 35.2%) than the group which did not meet the recommended level of PA (Table 1).
      Cumulative incidence curves are shown in Figure 1, Figure 2, Figure 3, Figure 4. After adjusting for confounding, patients who met the recommended guidelines for PA were significantly less likely to have died during the 2-year follow-up (adjusted hazard ratio (HR) [aHR] = 0.60, 95% confidence interval [CI] 0.38 to 0.95; Table 2). In contrast, we did not observe a statistically significant association of stroke (aHR 1.44, 95% CI 0.50 to 4.09), episode of major bleeding (aHR 0.86, 95% CI 0.56 to 1.32; Table 2), or a clinically relevant bleeding event (aHR = 1.02, 95% CI 0.82 to 1.27; Table 2) between the 2 groups.
      Figure 1
      Figure 1Cumulative incidence curve for mortality.
      Figure 2
      Figure 2Cumulative incidence curve for stroke.
      Figure 3
      Figure 3Cumulative incidence curve for major bleeding.
      Figure 4
      Figure 4Cumulative incidence curve for clinically relevant bleeding.
      Table 2Association between self-reported physical activity and clinical outcomes among older adults with atrial fibrillation
      Adjusted Variables: sociodemographic variables (Age, gender, race, marriage, education), Clinical variables (type of atrial fibrillation, body mass index, medical history of chronic lung disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and depression).
      VariablesMortalityStrokeMajor bleeding episodeClinically relevant bleeding
      Outcome among those engaged in recommended level of PA29 (4.6%)9 (1.4%)43 (6.9%)184 (29.3%)
      Outcome among those not engaged in recommended level of PA79 (12.8%)10 (1.6%)62 (10.1%)198 (32.1%)
      Crude HR (95% CI)0.39

      (0.25-0.59)
      0.88

      (0.36-2.17)
      0.69

      (0.47-1.01)
      0.90

      (0.74-1.10)
      Adjusted
      Adjusted Variables: sociodemographic variables (Age, gender, race, marriage, education), Clinical variables (type of atrial fibrillation, body mass index, medical history of chronic lung disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and depression).
      HR (95% CI)
      0.60

      (0.38-0.95)
      1.44

      (0.50-4.09)
      0.86

      (0.56-1.32)
      1.02

      (0.82-1.27)
      HR = hazard ratio; PA = physical activity.
      low asterisk Adjusted Variables: sociodemographic variables (Age, gender, race, marriage, education), Clinical variables (type of atrial fibrillation, body mass index, medical history of chronic lung disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and depression).

      Discussion

      In our study following 1,244 older adults with AF, we found that patients meeting the guideline-recommended level of PA had better survival.
      Regarding mortality, our finding is consistent with previous research. A retrospective study involving 1,366,422 patients AF with found that exercise-based cardiac rehabilitation was associated with lower odds of all-cause mortality.
      • Buckley BJR
      • Harrison SL
      • Fazio-Eynullayeva E
      • Underhill P
      • Lane DA
      • Thijssen DHJ
      • Lip GYH.
      Exercise-based cardiac rehabilitation and all-cause mortality among patients with atrial fibrillation.
      This conclusion is convincing because of the large number of patients involved. However, we are more precise in quantifying the PA level because we used a standardized questionnaire. In the EURObservational Research Programme on AF study, which included 2,442 patients with AF, higher level of PA (quantified by hours per week) was shown to be associated with a lower mortality risk within 1 year of follow-up.
      • Proietti M
      • Boriani G
      • Laroche C
      • Diemberger I
      • Popescu MI
      • Rasmussen LH
      • Sinagra G
      • Dan GA
      • Maggioni AP
      • Tavazzi L
      • Lane DA
      • Lip GYH
      EORP-AF General Pilot Registry Investigators. Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on atrial fibrillation (EORP-AF) General Registry.
      Another study involved 1,117 patients aged ≥18 years old from the third wave of the Nord-TrØndelag Health Study 3. The investigators gathered information on PA using the Nord-TrØndelag Health Study 1 questionnaire and divided the groups based on guideline-recommended level of exercise. They found that participants who met the recommended levels have significantly lower mortality than the inactive group and those did not reach the recommended PA level.
      • Garnvik LE
      • Malmo V
      • Janszky I
      • Ellekjær H
      • Wisløff U
      • Loennechen JP
      • Nes BM.
      Physical activity, cardiorespiratory fitness, and cardiovascular outcomes in individuals with atrial fibrillation: the HUNT study.
      Compared with these 2 studies, our study is more focused on the geriatric AF population—only the ones aged ≥65 years were included. Clinicians and health care providers should incorporate the recommended level of PA in the treatment plan of patients with AF and inform patients of its benefits.
      Despite the significant beneficial effect of meeting the recommended level of PA on mortality, no association was observed with stroke or bleeding (i.e., major bleeding and clinically relevant bleeding) in our study. In 1 study including 988 participants on anticoagulation for acute venous thrombosis, patients who were more active were found to experience less major bleeding. In comparison, the indication of anticoagulation use in our study group is AF, and we were more detailed in separating levels of PA (instead of using questions with 4 possible answers, we used a validated questionnaire).
      • Frey PM
      • Méan M
      • Limacher A
      • Jaeger K
      • Beer HJ
      • Frauchiger B
      • Aschwanden M
      • Rodondi N
      • Righini M
      • Egloff M
      • Osterwalder J
      • Kucher N
      • Angelillo-Scherrer A
      • Husmann M
      • Banyai M
      • Matter CM
      • Aujesky D.
      Physical activity and risk of bleeding in elderly patients taking anticoagulants.
      In another study including 377,234 participants from the United Kingdom, no causal relation was reported between PA and ischemic stroke, but there is no specific report on stroke rate among the AF population.
      • Bahls M
      • Leitzmann MF
      • Karch A
      • Teumer A
      • Dörr M
      • Felix SB
      • Meisinger C
      • Baumeister SE
      • Baurecht H.
      Physical activity, sedentary behavior and risk of coronary artery disease, myocardial infarction and ischemic stroke: a two-sample Mendelian randomization study.
      A meta-analysis including 23 studies reported that participants engaging in some PA have lower risk of both ischemic and hemorrhagic stroke events.
      • Lee CD
      • Folsom AR
      • Blair SN.
      Physical activity and stroke risk: a meta-analysis.
      Differences between our study findings and previous studies can be due to the cohort of older adults with AF, larger sample size, sociodemographic and clinical characteristics, instrument used to assess PA, and the period of follow-up. Future longitudinal studies should examine the effect of recommended levels of PA on bleeding and stroke risks among older adults with AF over a longer period of follow-up.
      In this observational study, it is possible that patients with fewer risk factors for mortality have greater capacity to engage in regular PA rather than the engagement of activity decreasing mortality risk. Although we adjusted for clinical factors shown to be linked with mortality among adults with AF,
      • Varona M
      • Coll-Vinent B
      • Martín A
      • Carbajosa J
      • Sánchez J
      • Tamargo J
      • Cancio M
      • Sánchez S
      • Del Arco C
      • Ríos J
      • Fernández-Simón A
      • Ormaetxe JM
      • Suero C
      EMERG-AF investigators (Appendix 1). Factors associated with poor prognosis in patients with atrial fibrillation: an emergency department perspective the EMERG-AF study.
      ,
      • Pokorney SD
      • Piccini JP
      • Stevens SR
      • Patel MR
      • Pieper KS
      • Halperin JL
      • Breithardt G
      • Singer DE
      • Hankey GJ
      • Hacke W
      • Becker RC
      • Berkowitz SD
      • Nessel CC
      • Mahaffey KW
      • Fox KA
      • Califf RM
      ROCKET AF Steering Committee and Investigators, ROCKET AF Steering Committee Investigators. Cause of death and predictors of all-cause mortality in anticoagulated patients With nonvalvular atrial fibrillation: data From ROCKET AF.
      there may be factors that may have increased mortality risk and impact the ability to exercise beyond those examined in this study. Randomized controlled trials to promote PA among older adults with AF who can safely engage in regular exercise can shed light on whether increasing PA can extend survival in this population. However, given the robust data demonstrating the physical and mental health benefits of PA,
      • Myers J.
      Cardiology patient pages. Exercise and cardiovascular health.
      ,
      • Paffenbarger Jr, RS
      • Hyde RT
      • Wing AL
      • Lee IM
      • Jung DL
      • Kampert JB.
      The association of changes in physical-activity level and other lifestyle characteristics with mortality among men.
      • Strath SJ
      • Kaminsky LA
      • Ainsworth BE
      • Ekelund U
      • Freedson PS
      • Gary RA
      • Richardson CR
      • Smith DT
      • Swartz AM
      American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health and Cardiovascular, Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, and Council. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association.
      • Malmo V
      • Nes BM
      • Amundsen BH
      • Tjonna AE
      • Stoylen A
      • Rossvoll O
      • Wisloff U
      • Loennechen JP.
      Aerobic interval training reduces the burden of atrial fibrillation in the short term: a randomized trial.
      • Watson KB
      • Carlson SA
      • Gunn JP
      • Galuska DA
      • O'Connor A
      • Greenlund KJ
      • Fulton JE CS
      Physical inactivity among adults aged 50 years and older - United States, 2014.
      • Jeong SW
      • Kim SH
      • Kang SH
      • Kim HJ
      • Yoon CH
      • Youn TJ
      • Chae IH.
      Mortality reduction with physical activity in patients with and without cardiovascular disease.
      we believe encouraging activity in this population is warranted.
      This study has additional several strengths. First, we used data from a large cohort of older adults with AF, with multiple co-morbidities and detailed demographic and clinical characteristics. Second, we used the Minnesota Leisure Time PA to quantify PA, which is a validated and standardized questionnaire.
      • Strath SJ
      • Kaminsky LA
      • Ainsworth BE
      • Ekelund U
      • Freedson PS
      • Gary RA
      • Richardson CR
      • Smith DT
      • Swartz AM
      American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health and Cardiovascular, Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, and Council. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association.
      Third, to the best of our knowledge, this study is among the first to explore whether guideline-recommended level of PA affect clinical outcomes in elderly patients with AF over a period of 2 years. Our study also has limitations. First, the majority of participants identified as non-Hispanic Whites, limiting the generalizability of our findings to adults of other races/ethnicities. Second, it is possible that participants misreported their engagement in specific PA, resulting in misclassification into adherent category. Third, only 19 participants experienced a stroke within the 2-year follow-up, limiting power for examining the association between PA and stroke. Therefore, these results should be interpreted with caution.
      • Simonsick EM
      • Lafferty ME
      • Phillips CL
      • Mendes de Leon CF
      • Kasl SV
      • Seeman TE
      • Fillenbaum G
      • Hebert P
      • Lemke JH.
      Risk due to inactivity in physically capable older adults.
      In conclusion, our study found that older adults with AF who engage in the recommended level of PA were less likely to die than adults who were less active over 2 years follow-up. Risk of stroke, major bleeding, and clinically relevant bleeding did not differ between groups. However, PA has been shown to have health benefits beyond mortality, such as modifying cardiovascular risk factors, decreasing AF symptoms and arrhythmia burdens, and boosting mood. Clinicians should encourage guideline-recommended PA, including integrating an exercise plan and cardiac rehabilitation programs, in the treatment plan for older adults with AF.

      Disclosures

      Dr. McManus has received research grant support from Apple Computer, Bristol-Myers Squibb, Boehringer-Ingelheim, Pfizer, Samsung, Philips Healthcare, and Biotronik; consultancy fees from Bristol-Myers Squibb, Pfizer, Flexcon, and Boston Biomedical Associates; and equity in Mobile Sense Technologies, Inc. (Farmington, Connecticut). The remaining authors have no conflicts of interest to declare.

      Reference

        • Ball J
        • Carrington MJ
        • McMurray JJ
        • Stewart S.
        Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century.
        Int J Cardiol. 2013; 167: 1807-1824
        • Samol A
        • Masin M
        • Gellner R
        • Otte B
        • Pavenstädt HJ
        • Ringelstein EB
        • Reinecke H
        • Waltenberger J
        • Kirchhof P.
        Prevalence of unknown atrial fibrillation in patients with risk factors.
        Europace. 2013; 15: 657-662
        • Staerk L
        • Sherer JA
        • Ko D
        • Benjamin EJ
        • Helm RH.
        Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes.
        Circ Res. 2017; 120: 1501-1517
        • Myers J.
        Cardiology patient pages. Exercise and cardiovascular health.
        Circulation. 2003; 107: e2-e5
        • Bosomworth NJ.
        Atrial fibrillation and physical activity: should we exercise caution?.
        Can Fam Physician. 2015; 61: 1061-1070
        • McManus DD
        • Kiefe C
        • Lessard D
        • Waring ME
        • Parish D
        • Awad HH
        • Marino F
        • Helm R
        • Sogade F
        • Goldberg R
        • Hayward R
        • Gurwitz J
        • Wang W
        • Mailhot T
        • Barton B
        • Saczynski J.
        Geriatric conditions and prescription of vitamin K antagonists vs. direct oral anticoagulants among older patients with atrial fibrillation: SAGE-AF.
        Front Cardiovasc Med. 2019; 6: 155
        • Lip GY
        • Nieuwlaat R
        • Pisters R
        • Lane DA
        • Crijns HJ.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • Saczynski JS
        • Sanghai SR
        • Kiefe CI
        • Lessard D
        • Marino F
        • Waring ME
        • Parish D
        • Helm R
        • Sogade F
        • Goldberg R
        • Gurwitz J
        • Wang W
        • Mailhot T
        • Bamgbade B
        • Barton B
        • McManus DD.
        Geriatric elements and oral anticoagulant prescribing in older atrial fibrillation patients: SAGE-AF.
        J Am Geriatr Soc. 2020; 68: 147-154
        • Fried LP
        • Tangen CM
        • Walston J
        • Newman AB
        • Hirsch C
        • Gottdiener J
        • Seeman T
        • Tracy R
        • Kop WJ
        • Burke G
        • McBurnie MA
        Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Kroenke K
        • Spitzer RL
        • Williams JB.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Ainsworth BE
        • Haskell WL
        • Whitt MC
        • Irwin ML
        • Swartz AM
        • Strath SJ
        • O'Brien WL
        • Bassett Jr, DR
        • Schmitz KH
        • Emplaincourt PO
        • Jacobs DR
        • Jr Leon AS
        Compendium of physical activities: an update of activity codes and MET intensities.
        Med Sci Sports Exerc. 2000; 32: S498-S504
        • Piercy KL
        • Troiano RP
        • Ballard RM
        • Carlson SA
        • Fulton JE
        • Galuska DA
        • George SM
        • Olson RD.
        The physical activity guidelines for Americans.
        JAMA. 2018; 320: 2020-2028
        • Schulman S
        • Kearon C
        Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.
        J Thromb Haemost. 2005; 3: 692-694
        • Wang W
        • Lessard D
        • Saczynski JS
        • Goldberg RJ
        • Mehawej J
        • Gracia E
        • McManus DD.
        Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation.
        Int J Cardiol Heart Vasc. 2021; 33100739
        • Buckley BJR
        • Harrison SL
        • Fazio-Eynullayeva E
        • Underhill P
        • Lane DA
        • Thijssen DHJ
        • Lip GYH.
        Exercise-based cardiac rehabilitation and all-cause mortality among patients with atrial fibrillation.
        J Am Heart Assoc. 2021; 10e020804
        • Proietti M
        • Boriani G
        • Laroche C
        • Diemberger I
        • Popescu MI
        • Rasmussen LH
        • Sinagra G
        • Dan GA
        • Maggioni AP
        • Tavazzi L
        • Lane DA
        • Lip GYH
        EORP-AF General Pilot Registry Investigators. Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on atrial fibrillation (EORP-AF) General Registry.
        Europace. 2017; 19: 535-543
        • Garnvik LE
        • Malmo V
        • Janszky I
        • Ellekjær H
        • Wisløff U
        • Loennechen JP
        • Nes BM.
        Physical activity, cardiorespiratory fitness, and cardiovascular outcomes in individuals with atrial fibrillation: the HUNT study.
        Eur Heart J. 2020; 41: 1467-1475
        • Frey PM
        • Méan M
        • Limacher A
        • Jaeger K
        • Beer HJ
        • Frauchiger B
        • Aschwanden M
        • Rodondi N
        • Righini M
        • Egloff M
        • Osterwalder J
        • Kucher N
        • Angelillo-Scherrer A
        • Husmann M
        • Banyai M
        • Matter CM
        • Aujesky D.
        Physical activity and risk of bleeding in elderly patients taking anticoagulants.
        J Thromb Haemost. 2015; 13: 197-205
        • Bahls M
        • Leitzmann MF
        • Karch A
        • Teumer A
        • Dörr M
        • Felix SB
        • Meisinger C
        • Baumeister SE
        • Baurecht H.
        Physical activity, sedentary behavior and risk of coronary artery disease, myocardial infarction and ischemic stroke: a two-sample Mendelian randomization study.
        Clin Res Cardiol. 2021; 110: 1564-1573
        • Lee CD
        • Folsom AR
        • Blair SN.
        Physical activity and stroke risk: a meta-analysis.
        Stroke. 2003; 34: 2475-2481
        • Varona M
        • Coll-Vinent B
        • Martín A
        • Carbajosa J
        • Sánchez J
        • Tamargo J
        • Cancio M
        • Sánchez S
        • Del Arco C
        • Ríos J
        • Fernández-Simón A
        • Ormaetxe JM
        • Suero C
        EMERG-AF investigators (Appendix 1). Factors associated with poor prognosis in patients with atrial fibrillation: an emergency department perspective the EMERG-AF study.
        Am J Emerg Med. 2021; 50: 270-277
        • Pokorney SD
        • Piccini JP
        • Stevens SR
        • Patel MR
        • Pieper KS
        • Halperin JL
        • Breithardt G
        • Singer DE
        • Hankey GJ
        • Hacke W
        • Becker RC
        • Berkowitz SD
        • Nessel CC
        • Mahaffey KW
        • Fox KA
        • Califf RM
        ROCKET AF Steering Committee and Investigators, ROCKET AF Steering Committee Investigators. Cause of death and predictors of all-cause mortality in anticoagulated patients With nonvalvular atrial fibrillation: data From ROCKET AF.
        J Am Heart Assoc. 2016; 5e002197
        • Paffenbarger Jr, RS
        • Hyde RT
        • Wing AL
        • Lee IM
        • Jung DL
        • Kampert JB.
        The association of changes in physical-activity level and other lifestyle characteristics with mortality among men.
        N Engl J Med. 1993; 328: 538-545
        • Strath SJ
        • Kaminsky LA
        • Ainsworth BE
        • Ekelund U
        • Freedson PS
        • Gary RA
        • Richardson CR
        • Smith DT
        • Swartz AM
        American Heart Association Physical Activity Committee of the Council on Lifestyle and Cardiometabolic Health and Cardiovascular, Exercise, Cardiac Rehabilitation and Prevention Committee of the Council on Clinical Cardiology, and Council. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association.
        Circulation. 2013; 128: 2259-2279
        • Malmo V
        • Nes BM
        • Amundsen BH
        • Tjonna AE
        • Stoylen A
        • Rossvoll O
        • Wisloff U
        • Loennechen JP.
        Aerobic interval training reduces the burden of atrial fibrillation in the short term: a randomized trial.
        Circulation. 2016; 133: 466-473
        • Watson KB
        • Carlson SA
        • Gunn JP
        • Galuska DA
        • O'Connor A
        • Greenlund KJ
        • Fulton JE CS
        Physical inactivity among adults aged 50 years and older - United States, 2014.
        MMWR Morb Mortal Wkly Rep. 2016; 65: 954-958
        • Jeong SW
        • Kim SH
        • Kang SH
        • Kim HJ
        • Yoon CH
        • Youn TJ
        • Chae IH.
        Mortality reduction with physical activity in patients with and without cardiovascular disease.
        Eur Heart J. 2019; 40: 3547-3555
        • Simonsick EM
        • Lafferty ME
        • Phillips CL
        • Mendes de Leon CF
        • Kasl SV
        • Seeman TE
        • Fillenbaum G
        • Hebert P
        • Lemke JH.
        Risk due to inactivity in physically capable older adults.
        Am J Public Health. 1993; 83: 1443-1450