Exercise Management

Atrial FibrillationChapter 9

Exercise Management

Pathophysiology

• Chronic atrial fibrillation is characterized by chaotic, rapid, and irregular atrial depolarizations. It is one of the most common arrhythmias encountered clinically, and it occurs more frequently with advancing age.• It most likely occurs by multiple reentrant circuits within the atria.•The irregular ventricular response can impair hemodynamic function

Exercise Management

• Complications of Atrial Fibrillation include:

– increased risk of thromboembolic events– rapid ventricular rates – incomplete ventricular filling, causing reduced cardiac output–decreased exercise capacity and fatigue.

Exercise Management

Effects on the Exercise Response

• rapid, irregular ventricular response• heart rate is higher (including maximal heart rate) at any level of exercise to compensate for the diminished stroke volume and cardiac output in Atrial Fibrillation (AF).• exercise tolerance is reduced (20%) in AF relative to normal sinus patients.• because of the variability in the diastolic filling period, the determination of systolic blood pressure can be difficult to assess and is poorly reproducible.

Exercise Management

Effects of Exercise Training

• Patients with AF would not be expected to have a training response particularly different from individuals in normal sinus rhythm.

•The major concern in terms of exercise training is the underlying heart disease, particularly valvular disease, chronic heart failure, and coronary artery disease.

Exercise ManagementManagement and Medications• 24hr ambulatory monitoring / INR monitoring if on anticoagulant•pharmacologic intervention to maintain sinus rhythm•involves converting the individual to normal sinus rhythm, or undergoing radiofrequency ablation•when AF is chronic, strategies to control the ventricular rate response and reduce the incidence of stroke. There is always the risk of thrombus /embolus formation.

Exercise Management

Recommendations for Exercise Testing(see Table 9.1, p.75, slide follows)

• Maximal exercise testing can be safely used to determine functional capabilities of the patient• The reduction in exercise capacity associated with AF is a direct function of the underlying heart disease.• Because underlying heart disease is common, small incremental exercise test protocols should be used.

Exercise Management

Recommendations for Exercise Testing

• Contraindications to exercise testing related to underlying conditions such as stability of chronic heart failure, valvular disease, or complex ventricular arrhythmias should take precedence over AF itself.• Otherwise AF patients may be safely taken to fatigue or shortness of breath endpoints• Age predicted maximal heart rate targets are particularly useless in AF because of the rapidand highly variable ventricular response. See also medications and precautions, p.75.

Exercise Management

Exercise Management

Recommendations for Exercise Programming

There are two major factors to consider in exercise programming:

1) concomitant or underlying heart disease

2) inherent unreliability of the pulse rate in prescribing exercise intensity.

Exercise Management

Recommendations for Exercise Programming(see Table 9.2, p. 76, next slide)

•Because AF is frequently accompanied by ischemic heart disease, chronic heart failure, or valvular heart disease, exercise programming considerations for these conditions should take precedence over AF.•Because of the chronically irregular ventricular rate, exercise intensity should be prescribed based on METs and perceived exertion levels.•Because AF can be intermittent (i.e., the client may be in AF one

day and in normal sinus rhythm the next); this will effect heart rate response to exercise, and exercise tolerance.•Ascertain rhythm on a daily basis

Exercise Management

End of Presentation