Advertisement

Weekly physical activity and incident atrial fibrillation in females – A dose-response meta-analysis

Published:November 07, 2022DOI:https://doi.org/10.1016/j.ijcard.2022.11.007

      Highlights

      • If there is a J shaped relationship between PA and AF remains uncertain.
      • We assessed this relationship in females from the general population.
      • A meta-analytic dose response model was adopted.
      • An inverse non-linear relationship was demonstrated.
      • Up to 50METs- h/w of moderate or vigorous PA seem to safely reduce the risk of AF.

      Abstract

      Background

      For years, physical activity (PA) has been considered a mixed blessing in terms of the risk of incident atrial fibrillation (AF). Previous analyses have had equivocal results regarding the cut-off of PA level beyond which AF risk increases, if such a limit really does exist. Data regarding females in particular have been scarce.

      Methods

      We performed a dose-response meta-analysis to investigate the relationship between weekly PA and the risk for AF in females. Major electronic databases were searched for studies assessing the association between leisure time PA and the risk for incident AF in females from the general population. The linearity of the dose-response curve was assessed using the restricted cubic spline model.

      Results

      A total of 15 studies, which involved 1,821,422 females, were included in the final analysis. AF incidence was 3.7%. Dose-response analysis revealed an inverse nonlinear relationship between weekly PA and the risk for incident AF (p for linearity <0.0001). No significant heterogeneity was documented (I2 = 37%). Cautious interpretation is needed for PA exceeding 50 metabolic equivalents of task- hours per week (METs- h/w), due to limited available data for these high levels of PA.

      Conclusion

      According to this analysis, physicians can safely advise females to perform up to 50METs- h/w of moderate or vigorous PA, to reduce the risk for future AF. Interestingly, significant benefit can be attained even at low levels of regular weekly PA.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to International Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hindricks G.
        • Potpara T.
        • Dagres N.
        • et al.
        Corrigendum to: 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European heart rhythm association (EHRA) of the ESC.
        Eur. Heart J. 2021; 42: 4194
        • Benjamin E.J.
        • Muntner P.
        • Alonso A.
        • et al.
        Heart disease and stroke Statistics-2019 update: a report from the American Heart Association [published correction appears in circulation. 2020 Jan 14;141(2):e33].
        Circulation. 2019; 139: e56-e528
        • Feinberg W.M.
        • Blackshear J.L.
        • Laupacis A.
        • Kronmal R.
        • Hart R.G.
        Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications.
        Arch. Intern. Med. 1995; 155: 469-473
        • Thrall G.
        • Lane D.
        • Carroll D.
        • Lip G.Y.
        Quality of life in patients with atrial fibrillation: a systematic review.
        Am. J. Med. 2006; 119
        • Hobbelt A.H.
        • Siland J.E.
        • Geelhoed B.
        • et al.
        Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort: data of the PREVEND study.
        Europace. 2017; 19: 226-232
        • Hobbelt A.H.
        • Siland J.E.
        • Geelhoed B.
        • et al.
        Clinical, biomarker, and genetic predictors of specific types of atrial fibrillation in a community-based cohort: data of the PREVEND study.
        Europace. 2017; 19: 226-232
        • Fagard R.H.
        Exercise characteristics and the blood pressure response to dynamic physical training.
        Med. Sci. Sports Exerc. 2001; 33: S484-S494
        • Wang Y.
        • Xu D.
        Effects of aerobic exercise on lipids and lipoproteins.
        Lipids Health Dis. 2017; 16: 132
        • Wallberg-Henriksson H.
        • Gunnarsson R.
        • Henriksson J.
        • et al.
        Increased peripheral insulin sensitivity and muscle mitochondrial enzymes but unchanged blood glucose control in type I diabetics after physical training.
        Diabetes. 1982; 31: 1044-1050
        • Lear S.A.
        • Hu W.
        • Rangarajan S.
        • Gasevic D.
        • Leong D.
        • Iqbal R.
        • Casanova A.
        • Swaminathan S.
        • Anjana R.M.
        • Kumar R.
        • Rosengren A.
        • Wei L.
        • Yang W.
        • Chuangshi W.
        • Huaxing L.
        • Nair S.
        • Diaz R.
        • Swidon H.
        • Gupta R.
        • Mohammadifard N.
        • Yusuf S.
        The effect of PA on mortality and cardiovascular disease in 130000 people from 17 high-income, middle-income, and low-income countries: the PURE study.
        Lancet (London, England). 2017; 390: 2643-2654
        • Aizer A.
        • Gaziano J.M.
        • Cook N.R.
        • Manson J.E.
        • Buring J.E.
        • Albert C.M.
        Relation of vigorous exercise to risk of atrial fibrillation.
        Am. J. Cardiol. 2009; 103: 1572-1577
        • Elosua R.
        • Arquer A.
        • Mont L.
        • et al.
        Sport practice and the risk of lone atrial fibrillation: a case-control study [published correction appears in Int J Cardiol. 2007 Dec 15;123(1):74].
        Int. J. Cardiol. 2006; 108: 332-337
        • Elliott A.D.
        • Linz D.
        • Mishima R.
        • et al.
        Association between physical activity and risk of incident arrhythmias in 402 406 individuals: evidence from the UK biobank cohort.
        Eur. Heart J. 2020; 41: 1479-1486
        • Nielsen J.R.
        • Wachtell K.
        • Abdulla J.
        The relationship between physical activity and risk of atrial fibrillation-a systematic review and Meta-analysis.
        J. Atr. Fibril. 2013; 5: 789
        • Morseth B.
        • Graff-Iversen S.
        • Jacobsen B.K.
        • Jørgensen L.
        • Nyrnes A.
        • Thelle D.S.
        • Vestergaard P.
        • Løchen M.L.
        Physical activity, resting heart rate, and atrial fibrillation: the Tromsø study.
        Eur. Heart J. 2016; 37: 2307-2313
        • Wan Q.
        • Zhou Y.
        • Zhu W.
        • Liu X.
        Sex-specific exposure-effect relationship between physical activity and incident atrial fibrillation in the general population: a dose-response meta-analysis of 16 prospective studies.
        Front. Cardiovasc. Med. 2021; 8710071
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J. Clin. Epidemiol. 2009; 62: e1-e34
      1. Physical Activity Guidelines for Americans. 2nd edition. 2022
        • National Institutes of Health
        Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.
        (Available online at:) (Accessed: July 19, 2022)
        • Harrell Jr., F.E.
        • Lee K.L.
        • Pollock B.G.
        Regression models in clinical studies: determining relationships between predictors and response.
        J. Natl. Cancer Inst. 1988 Oct 5; 80: 1198-1202
        • Ryan R.
        • Cochrane Consumers and Communication Review Group
        Heterogeneity and subgroup analyses in Cochrane Consumers and Communication Group reviews: planning the analysis at protocol stage.
        2022 (Available online at:) (Accessed: July 19, 2022)
        • Everett B.M.
        • Conen D.
        • Buring J.E.
        • Moorthy M.V.
        • Lee I.M.
        • Albert C.M.
        Physical activity and the risk of incident atrial fibrillation in women.
        Circ. Cardiovasc. Qual. Outcomes. 2011; 4: 321-327
        • Thelle D.S.
        • Selmer R.
        • Gjesdal K.
        • et al.
        Resting heart rate and physical activity as risk factors for lone atrial fibrillation: a prospective study of 309,540 men and women.
        Heart. 2013; 99: 1755-1760
        • Azarbal F.
        • Stefanick M.L.
        • Salmoirago-Blotcher E.
        • et al.
        Obesity, physical activity, and their interaction in incident atrial fibrillation in postmenopausal women.
        J. Am. Heart Assoc. 2014; 3e001127
        • Huxley R.R.
        • Misialek J.R.
        • Agarwal S.K.
        • et al.
        Physical activity, obesity, weight change, and risk of atrial fibrillation: the atherosclerosis risk in communities study.
        Circ. Arrhythm. Electrophysiol. 2014; 7: 620-625
        • Drca N.
        • Wolk A.
        • Jensen-Urstad M.
        • Larsson S.C.
        Physical activity is associated with a reduced risk of atrial fibrillation in middle-aged and elderly women.
        Heart. 2015; 101: 1627-1630
        • Morseth B.
        • Graff-Iversen S.
        • Jacobsen B.K.
        • et al.
        Physical activity, resting heart rate, and atrial fibrillation: the Tromsø study.
        Eur. Heart J. 2016; 37: 2307-2313
        • Mokhayeri Y.
        • Hashemi-Nazari S.S.
        • Mansournia M.A.
        • Soori H.
        • Khodakarim S.
        The association between physical activity and atrial fibrillation applying the Heaviside function in survival analysis: the multi-ethnic study of atherosclerosis.
        Epidemiol. Health. 2017; 39e2017024
        • Albrecht M.
        • Koolhaas C.M.
        • Schoufour J.D.
        • et al.
        Physical activity types and atrial fibrillation risk in the middle-aged and elderly: the Rotterdam study.
        Eur. J. Prev. Cardiol. 2018; 25: 1316-1323
        • Jin M.N.
        • Yang P.S.
        • Song C.
        • et al.
        Physical activity and risk of atrial fibrillation: a Nationwide cohort study in general population.
        Sci. Rep. 2019; 9: 13270
        • Choi Y.W.
        • Park M.
        • Lim Y.H.
        • et al.
        Independent effect of physical activity and resting heart rate on the incidence of atrial fibrillation in the general population.
        Sci. Rep. 2019; 9: 11228
        • O’Neal W.T.
        • Bennett A.
        • Singleton M.J.
        • et al.
        Objectively measured physical activity and the risk of atrial fibrillation (from the REGARDS study).
        Am. J. Cardiol. 2020; 128: 107-112
        • Park C.S.
        • Han K.D.
        • Choi E.K.
        • et al.
        Lifestyle is associated with atrial fibrillation development in patients with type 2 diabetes mellitus.
        Sci. Rep. 2021; 11: 4676
        • Boursiquot B.C.
        • Bellettiere J.
        • LaMonte M.J.
        • LaCroix A.Z.
        • Perez M.V.
        Sedentary behavior and atrial fibrillation in older women: the OPACH study.
        J. Am. Heart Assoc. 2022; 11e023833
        • Fletcher G.
        • Alam A.B.
        • Li L.
        • Norby F.L.
        • Chen L.Y.
        • Soliman E.Z.
        • Alonso A.
        Association of physical activity with the incidence of atrial fibrillation in persons>65 years old: the atherosclerosis risk in communities (ARIC) study.
        BMC Cardiovasc. Disord. 2022; 22: 196
        • Wiebe C.G.
        • Gledhill N.
        • Warburton D.E.
        • Jamnik V.K.
        • Ferguson S.
        Exercise cardiac function in endurance-trained males versus females.
        Clin. J. Sport Med. 1998; 8: 272-279
        • Best S.A.
        • Okada Y.
        • Galbreath M.M.
        • et al.
        Age and sex differences in muscle sympathetic nerve activity in relation to haemodynamics, blood volume and left ventricular size.
        Exp. Physiol. 2014; 99: 839-848
        • Piro M.
        • Della Bona R.
        • Abbate A.
        • Biasucci L.M.
        • Crea F.
        Sex-related differences in myocardial remodeling.
        J. Am. Coll. Cardiol. 2010; 55: 1057-1065
        • Dart A.M.
        • Du X.J.
        • Kingwell B.A.
        Gender, sex hormones and autonomic nervous control of the cardiovascular system.
        Cardiovasc. Res. 2002 Feb 15; 53: 678-687
        • Charkoudian N.
        • Joyner M.J.
        Physiologic considerations for exercise performance in women.
        Clin. Chest Med. 2004; 25: 247-255
        • McEvoy B.P.
        • Visscher P.M.
        Genetics of human height.
        Econ. Hum. Biol. 2009 Dec; 7: 294-306
        • Levin M.G.
        • Judy R.
        • Gill D.
        • Vujkovic M.
        • Verma S.S.
        • Bradford Y.
        • Center Regeneron Genetics
        • Ritchie M.D.
        • Hyman M.C.
        • Nazarian S.
        • Rader D.J.
        • Voight B.F.
        • Damrauer S.M.
        Genetics of height and risk of atrial fibrillation: a Mendelian randomization study.
        PLoS Med. 2020 Oct 8; 17e1003288
        • Barnett T.A.
        • Gauvin L.
        • Craig C.L.
        • Katzmarzyk P.T.
        Distinct trajectories of leisure time physical activity and predictors of trajectory class membership: a 22 year cohort study.
        Int. J. Behav. Nutr. Phys. Act. 2008 Nov 7; 5: 57
        • Ricci C.
        • Gervasi F.
        • Gaeta M.
        • Smuts C.M.
        • Schutte A.E.
        • Leitzmann M.F.
        Physical activity volume in relation to risk of atrial fibrillation. A non-linear meta-regression analysis.
        Eur. J. Prev. Cardiol. 2018; 25: 857-866
        • Mishima R.S.
        • Verdicchio C.V.
        • Noubiap J.J.
        • et al.
        Self-reported physical activity and atrial fibrillation risk: a systematic review and meta-analysis.
        Heart Rhythm. 2021; 18: 520-528
        • Mohanty S.
        • Mohanty P.
        • Tamaki M.
        • et al.
        Differential association of exercise intensity with risk of atrial fibrillation in men and women: evidence from a meta-analysis.
        J. Cardiovasc. Electrophysiol. 2016; 27: 1021-1029
        • Molina L.
        • Mont L.
        • Marrugat J.
        • et al.
        Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study.
        Europace. 2008; 10: 618-623
        • Karjalainen J.
        • Kujala U.M.
        • Kaprio J.
        • Sarna S.
        • Viitasalo M.
        Lone atrial fibrillation in vigorously exercising middle aged men: case-control study.
        BMJ. 1998; 316: 1784-1785
        • La Gerche A.
        • Claessen G.
        Increased flow, dam walls, and upstream pressure: the physiological challenges and atrial consequences of intense exercise.
        JACC Cardiovasc. Imaging. 2016; 9: 1389-1391
        • Benito B.
        • Gay-Jordi G.
        • Serrano-Mollar A.
        • et al.
        Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training.
        Circulation. 2011; 123: 13-22
        • Wilhelm M.
        • Roten L.
        • Tanner H.
        • Wilhelm I.
        • Schmid J.P.
        • Saner H.
        Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes.
        Am. J. Cardiol. 2011; 108: 580-585
        • Brugger N.
        • Krause R.
        • Carlen F.
        • et al.
        Effect of lifetime endurance training on left atrial mechanical function and on the risk of atrial fibrillation.
        Int. J. Cardiol. 2014; 170: 419-425
        • Opondo M.A.
        • Aiad N.
        • Cain M.A.
        • et al.
        Does high-intensity endurance training increase the risk of atrial fibrillation? A longitudinal study of left atrial structure and function.
        Circ. Arrhythm. Electrophysiol. 2018; 11e005598
        • Chen Y.C.
        • Voskoboinik A.
        • Gerche A.
        • Marwick T.H.
        • McMullen J.R.
        Prevention of pathological atrial remodeling and atrial fibrillation: JACC state-of-the-art review.
        J. Am. Coll. Cardiol. 2021; 77: 2846-2864
        • Oláh A.
        • Barta B.A.
        • Sayour A.A.
        • Ruppert M.
        • Virág-Tulassay E.
        • Novák J.
        • Varga Z.V.
        • Ferdinandy P.
        • Merkely B.
        • Radovits T.
        Balanced intense exercise training induces atrial oxidative stress counterbalanced by the antioxidant system and atrial hypertrophy that is not associated with pathological remodeling or Arrhythmogenicity.
        Antioxidants (Basel, Switzerland). 2021; 10: 452
        • Goette A.
        • Kalman J.M.
        • Aguinaga L.
        • Akar J.
        • Cabrera J.A.
        • Chen S.A.
        • Chugh S.S.
        • Corradi D.
        • D’Avila A.
        • Dobrev D.
        • Fenelon G.
        • Gonzalez M.
        • Hatem S.N.
        • Helm R.
        • Hindricks G.
        • Ho S.Y.
        • Hoit B.
        • Jalife J.
        • Kim Y.H.
        • Lip G.Y.
        • Reviewers Document
        EHRA/HRS/APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication.
        Europace. 2016; 18: 1455-1490
        • Lakin R.
        • Polidovitch N.
        • Yang S.
        • Guzman C.
        • Gao X.
        • Wauchop M.
        • Burns J.
        • Izaddoustdar F.
        • Backx P.H.
        Inhibition of soluble TNFα prevents adverse atrial remodeling and atrial arrhythmia susceptibility induced in mice by endurance exercise.
        J. Mol. Cell. Cardiol. 2019; 129: 165-173
        • Borges J.P.
        • da Silva Verdoorn K.
        Cardiac ischemia/reperfusion injury: the beneficial effects of exercise.
        Adv. Exp. Med. Biol. 2017; 999: 155-179
        • Leosco D.
        • Rengo G.
        • Iaccarino G.
        • et al.
        Exercise promotes angiogenesis and improves beta-adrenergic receptor signalling in the post-ischaemic failing rat heart.
        Cardiovasc. Res. 2008; 78: 385-394
        • Vettor R.
        • Valerio A.
        • Ragni M.
        • et al.
        Exercise training boosts eNOS-dependent mitochondrial biogenesis in mouse heart: role in adaptation of glucose metabolism.
        Am. J. Physiol. Endocrinol. Metab. 2014; 306: E519-E528
        • Kasapis C.
        • Thompson P.D.
        The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review.
        J. Am. Coll. Cardiol. 2005; 45: 1563-1569
        • Kokkinos P.
        • Myers J.
        Exercise and physical activity: clinical outcomes and applications.
        Circulation. 2010; 122: 1637-1648