Eight Lifestyle Changes All Patients Should Make To Reduce The Recurrence Of Atrial Fibrillation

Previously, the skeptical cardiologist answered the question “Why Did I Go Into Atrial fibrillation?

An equally important question is “how can I reduce the chances that I have more spells of atrial fibrillation (AF)?”

I spend a fair amount of time discussing with my AF patients what lifestyle changes they can make in this regard. I’ve discovered, however, that many AF patients I am seeing for a second opinion seem unaware of the changes they can make to minimize AF recurrence.

Herein I give you the eight most important changes you can make to minimize both the onset and the recurrence of AF.

  1. Eliminate or substantially reduce alcohol.
  2. Lose weight if you are obese.
  3. Stop smoking. Stopping is associated with a 36% lower risk of AF.
  4. Get your blood pressure under good control.
  5. Get regular aerobic exercise. At least 150 minutes of moderate cardio exercise weekly.
  6. Eat A Healthy Diet. Don’t Eat Crap (as Younger Next Year says). In general, because obesity is such a big factor  in AF, I am fine with whatever diet plan has you at a BMI <28. Healthy diets controlling weight avoid ultra-processed foods, sugar-sweetened beverages, and minimize white rice, pasta, pastries, and potatoes. These diets include lots of fresh vegetables, nuts, olive oil, and fish. Full fat yogurt and cheese are fine in moderation. Eat real food, mostly plants, not too much as Michael Pollan has famously said.
  7. Get high-quality sleep. This means treating any sleep apnea properly in addition to standard advice for getting a good night’s sleep. The risk of AF is four times higher in patients with obstructive sleep apnea (OSA) independent of other confounding variables
  8. Reduce stress. Easier said than done I know. Everything from meditation to Yoga to retiring or cutting back at work to psychotherapy can be tried in this category. Go with whatever works for you. Knowing when you are in or out of AF by utilizing personal ECG monitoring devices may help reduce stress, especially if used under physician supervision.

Let’s dig a little deeper into some specific recent evidence on three which have a huge impact: alcohol, exercise, and obesity.

Alcohol and Atrial Fibrillation

In March, I wrote about the alcohol AF trial recently published in NEJM:

The Alcohol-AF Trial. Binge alcohol consumption (holiday heart) can trigger atrial fibrillation (AF) and observational studies show a higher incidence of AF with higher amounts of alcohol consumption.

This trial was the first-ever randomized controlled trial of alcohol abstinence in moderate drinkers with paroxysmal AF (minimum 2 episodes in the last 6 months) or persistent AF requiring cardioversion.

Participants consumed >/= 10 standard drinks per week and were randomized to abstinence or usual consumption.

Participants underwent comprehensive rhythm monitoring with implantable loop recorders or existing pacemakers and twice-daily AliveCor monitoring for 6 months.

Abstinence prolonged AF-free survival by 37% (118 vs 86 days) and lowered the AF burden from 8.2% to 5.6%

AF related hospitalizations occurred in 9% of abstinence patients versus 20% of controls

Participants in the abstinence arm also experienced improved symptom severity, weight loss and BP control.

This trial gives me precise numbers to present to my AF patients to show them how important eliminating alcohol consumption is if they want to have fewer AF episodes. The study further emphasizes lifestyle changes (including weight loss, exercise, and stress-reduction) can dramatically reduce the incidence of atrial fibrillation.

Obesity and Atrial Fibrillation

We have known for some time of a strong association between obesity and atrial fibrillation. We also know we can make sheep go into atrial fibrillation by making them obese and creating a diseased, fat-infiltrated left atrium.

More recently we have solid evidence that sustained weight reduction can significantly reduce the recurrence of AF.

The Australian LEGACY study took 355 AF AF patients with BMI>27 and offered them a weight management program:

Weight loss was categorized as group 1 (≥ 10%), group 2 (3% to 9%), and group 3 (<3%). Weight trend and/or fluctuation was determined by yearly follow-up. Endpoints included impact on the AF severity scale and 7-day ambulatory monitoring.

Weight loss ≥ 10% resulted in a 6-fold  greater probability of no AF recurrences compared with the other 2 groups. High weight fluctuation doubled the risk of AF recurrence.

Of course, all these factors are interrelated. Exercise, diet, stress, alcohol consumption, and sleep quality all impact weight control and obesity. Patients with AF should be working on all 8 levers for optimal benefit.

Given the LEGACY study findings, if you have AF and are obese, you should be using all lifestyle factors at your disposal to get your body weight down >10%. Do this in a slow and steady fashion with lifestyle changes that are sustainable for the rest of your life. You want to lose that weight and keep it off.

Exercise And AF

The most compelling evidence for the independent role of exercise in reducing AF comes from a Norwegian study of 51 patients with AF who were randomized either to aerobic interval training (AIT) or to their regular exercise habits. The patients randomized to AIT engaged in four 4-minute bouts of high-intensity (85 to 95% peak heart rate) aerobic exercise interspersed with 3 minutes of recovery.

There was a significant reduction in AF burden (measured by implanted loop recorders) in the exercise group, with the mean time in AF dropping from 8.1% to 4.8%, with no significant change in the control group. Patients in the exercise group experienced fewer and less severe symptoms whereas the non-exercising, control group had no change. In comparison with controls, patients randomly assigned to exercise also increased their peak oxygen consumption (Vo2peak), cardiac function, and quality of life, while improving body mass index and blood lipids

Screen Shot 2020-02-02 at 12.19.44 PM
Atrial fibrillation (AF) burden in patients with AF during the study. Mean time in AF was measured by an implanted loop recorder (n=36) before, during, and after 12 weeks of aerobic interval training (exercise) or usual care (control). Patients without AF during the study period are excluded. Mean changes from baseline to follow up were −6.2±8.9 percentage points (pp), P=0.02 for exercise; 4.8±12.5 pp, P=0.09 for control; and 11.0±3.9 pp, P=0.007 between groups. Error bars show the 95% confidence interval.

An accompanying editorial provides this graphic on the benefits of exercise training in AF

 

For all you readers without AF you can minimize your chances of developing AF by following these lifestyle recommendations.

Afibrillatorily Yours,

-ACP

N.B. A PDF summary of the 8 factors is available here (Lifestyle changes Afib)

N.B.2 For those wishing to mimic the Norwegian AIT protocol here is the complete description:

Endurance training was performed as walking or running on a treadmill 3 times a week for 12 weeks. Each session started with a 10-minute warmup at 60% to 70% of maximal heart rate obtained at exercise testing (HRpeak), followed by four 4-minute intervals at 85% to 95% of HRpeak with 3 minutes of active recovery at 60% to 70% of HRpeakbetween intervals, ending with a 5-minute cooldown period. During AF, patients exercised at the same treadmill speed and inclination as in the previous sessions in sinus rhythm, with the Borg scale of 6 to 20 as an aid to control intensity. When familiar with the training regimen, patients were allowed to perform 1 exercise per week at home, where exercise intensity was documented with a heart rate monitor (RS300X, Polar Electro, Kempele, Finland).

 

 

 

 

15 thoughts on “Eight Lifestyle Changes All Patients Should Make To Reduce The Recurrence Of Atrial Fibrillation”

  1. Any comments about the relatively new “Smart BMI” calculators, that adjust for sex and age? I’m 75, and the adjustment is substantial.

    Thanks for this blog — it’s fascinating reading.

    1. It’s interesting. Plugging my numbers in at (https://www.smartbmicalculator.com) I get a 32/70 score which is good.
      The graphs/curves slowly increase with age the BMI that is considered ideal. A BMI of >25 is obese for those in the 20s whereas up to 30 for those >75 years. Of course, this takes into account the fact that we all accumulate central body fat with aging. Given that there is a similar progressive increase in the rate of afib are the two related? I chose a non age-related BMI goal of <28 as the weight management study I mentioned enrolled patients with BMI>27. The vast majority of my AF patients are between ages 40 and 75 and if their BMI is >28 they have a noticeable amount of abdominal obesity.

  2. I would like to point out that the J curve applies with respect to exercise and atrial fibrillation occurrence and recurrence. Sedentary life-style is one end of the J. The other end: Some of us find exercise so rewarding that we do more of it. And then more. Intensive cross-country skying, marathons and ultra marathons, Iron Man challenge, working as a forest ranger – all increase the risk of this most common arrhythmia. (A statistical “risk” factor is the actual cause for some particular individuals.)
    Moderation wins. But each one of us has our own “moderation”. Finding that low point in our J can be a challenge.

  3. I have never been an alcohol drinker as I have a genetic predisposition not to enjoy alcohol. Recent well-done studies show there is no CV or other benefit to drinking alcohol. These studies have controlled for the “sick quitter” effect. One recent study was a randomized Mendelian study which showed that those who drink moderately do not have any fewer CHD events than those who do not drink at all. This suggest that alcohol is probably not the reason some studies have shown that moderate drinkers have fewer CHD events. As for the other 7 recommendations, I can’t think of any that will do more good for anyone healthy or otherwise. Leave the booze alone, don’t smoke, avoid pain killers and other substance abuse and eat a heart healthy diet. In fact, factor analysis of heart disease shows the three main factors to be smoking at 36%, obesity 20%, and lack of regular aerobic exercise 12%.

  4. I noticed in your lifestyle changes to prevent AFIB “moderate exercise”. In past reading I had gleaned that EXCESSIVE vigorous exercise might be more detrimental than beneficial. I recently read a large European cohort study ( https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz897/5709157 ) that seems to corroborate that. This study compared exercise calculated using “METs” or metabolic equivalents (further explanation of METs
    ( https://www.cooperinstitute.org/2017/12/07/using-met-minutes-to-track-volume-of-physical-activity ) with rates of AFIB as well as a breakdown between genders. The study revealed there certainly is a threshold for benefit/prevention especially in males of AFIB as well as other arrythmias.

    What caught my attention was in the secondary analysis of data it was found that at extreme doses of vigorous activity, there was a 12% increase in AFIB incidents for men but curiously an 8-16% decrease in AFIB incidences with women using the same exercise threshold. Maybe the old saying “everything in moderation” certainly might be applicable (for men at least).

  5. Just before reading this article, I was re-reading your thought-provoking critique of Hippocrates’ oft-quoted “let food be thy medicine” axiom. Having this critique freshly in my mind, I found myself a little confused at the diet recommendations of staying away from white rice, pastas, and potatoes. Even if we set aside, for the moment, the white rice and the pasta as refined or processed foods, potatoes are just as nature made them. And potatoes have been recognized as valuable food items across a variety of cultures, historical periods, and cuisines. . . . Isn’t vilifying them the same kind of food moralizing you were speaking of in the Hippocrates article?

    It appears to me that the world of traditional medicine has the same tendency as alternative medicine practitioners of embracing/rejecting foods in the name of health. Perhaps this is simply human nature? And perhaps the food equation is not nearly as simple as we wish it could be!

    1. Agree. But see my post on my potato theory of obesity. The vast majority of potatoes consumed prepared in a way that converts them into a hard to resist taste sensation that tends to be an add on to meals and results in extra calories.
      I am fine with potatoes prepared at home.

      1. Looking forward to reading your potato post! Will definitely look it up 🙂

        In several years of researching health issues and finding the diet connection coming up again and again from all sources, it is clear that we can’t separate diet from nutrients and can’t separate nutrients from body function (and, as an author from a totally different discipline points out, scurvy is one of our oldest examples of this). What I have most appreciated in this search are the practitioners–both traditional and alternative–who have been willing to stop oversimplifying the food equation, stop demonizing/pedestalizing this tuber/fruit/protein/sugar or that green/berry/sprout/sugar, and who open up the conversation to the more complex issues of preparation and nutrients and body differences (not to mention growing methods and marketing!). Thank you for being willing to have these helpful conversations.

    1. Caffeine and chocolate are rare triggers in my patient population. I have found specific foods/beverages for individual patients can be a trigger. One of my patients went into afib eery time she ate ice cream. However, these fall in my opinion into a category of triggers which you clearly recognize and can easily avoid once recognized, not lifestyle factors which are not so clearly related to AFIB onset.

  6. I am curious if atrial fib and atrial flutter are separate syndromes or overlap. Are articles and recommendations for atrial fib including or appropriate for atrial flutter.

    1. Bruce,
      Good question. I’ve been meaning to write a post on flutter so stay tuned for a more detailed answer.
      Briefly, fib/flutter are handled similarly when it comes to anticoagulation (although i feel flutter is less likely to be associated with thrombus/stroke.)
      Drug treatment they are also generally lumped together although there are really important nuanced differences that I utilize in my treatment approach.
      The big difference in treatment is when it comes to ablation: flutter ablation is much more straightfoward, safe and effective compared to afib ablation.
      This is due to flutter originating from a well-defined pathway in the RA versus fib originating from a confusing conglomerate of sources in the LA/pulmonay vein region.
      Dr P

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