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

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. 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 stroke1Ball 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: 1807-1824Abstract Full Text Full Text PDF PubMed Scopus (421) Google Scholar,2Samol 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: 657-662Crossref PubMed Scopus (50) Google Scholar and contributes to the development of heart failure, myocardial infarction, and all-cause mortality.3Staerk L Sherer JA Ko D Benjamin EJ Helm RH. Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes.Circ Res. 2017; 120: 1501-1517Crossref PubMed Scopus (450) Google Scholar 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.4Myers J. Cardiology patient pages. Exercise and cardiovascular health.Circulation. 2003; 107: e2-e5Crossref PubMed Google Scholar 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.5Bosomworth NJ. Atrial fibrillation and physical activity: should we exercise caution?.Can Fam Physician. 2015; 61: 1061-1070PubMed Google Scholar Using data collected from a large prospective study,6McManus 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: 155Crossref PubMed Scopus (8) Google Scholar 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. 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, 2020.6McManus 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: 155Crossref PubMed Scopus (8) Google Scholar 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) ≥2.7Lip 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: 263-272Abstract Full Text Full Text PDF PubMed Scopus (4732) Google Scholar 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.8Saczynski 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: 147-154Crossref PubMed Scopus (40) Google Scholar 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,9Fried 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-M156Crossref PubMed Google Scholar and Patient Health Questionnaire PHQ-9,10Kroenke K Spitzer RL Williams JB. The PHQ-9: validity of a brief depression severity measure.J Gen Intern Med. 2001; 16: 606-613Crossref PubMed Scopus (21236) Google Scholar 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.11Ainsworth 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-S504Crossref PubMed Scopus (6162) Google Scholar 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.12Piercy KL Troiano RP Ballard RM Carlson SA Fulton JE Galuska DA George SM Olson RD. The physical activity guidelines for Americans.JAMA. 2018; 320: 2020-2028Crossref PubMed Scopus (2092) Google Scholar 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.13Schulman 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: 692-694Crossref PubMed Scopus (3050) Google Scholar 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.13Schulman 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: 692-694Crossref PubMed Scopus (3050) Google Scholar,14Wang 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; 33100739PubMed Google Scholar 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).14Wang 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; 33100739PubMed Google Scholar 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). 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 fibrillationVariablesMET recommended level of physical activityp ValueYes (n = 628)No (n = 616)Age (median (lower, upper quartile))74 (69,79)76 (71,82)<0.001Men346 (55.1%)291 (47.2%)0.006BMI (median (lower, upper quartile)) (kg/m2)28.7 (25.7, 33.0)29.7 (25.8, 34.1)0.034Non-Hispanic white549 (87.6%)507 (82.3%)0.010Married384 (62.2%)310 (51.1%)<0.001College graduate or higher308 (50.0%)219 (36.3%)<0.001Type of AF0.044 Paroxysmal390 (62.1%)351 (57.0%) Persistent153 (24.4%)156 (25.3%) Permanent26 (4.1%)47 (7.6%)Time AF (median co-morbidity index (median score (median score (median artery vascular of = atrial BMI = body mass in a AF = atrial BMI = body mass the clinical co-morbidities, participants in the who met the recommended PA level were less likely to to chronic disease vs coronary artery disease vs diabetes vs heart vs vs myocardial vs peripheral vascular disease vs kidney disease vs stroke vs and symptoms of depression vs than the which did not meet the recommended level of PA (Table are shown in After for patients who met the recommended guidelines for PA were less likely to during the 2-year follow-up (adjusted hazard ratio = 0.60, 95% confidence interval 0.38 to In we did not a association of stroke 95% CI to episode of major bleeding 95% CI to or a clinically relevant bleeding = 95% CI to between the 2 for for major for clinically relevant between self-reported physical activity and clinical outcomes among older adults with atrial variables gender, race, variables of atrial body mass medical history of chronic disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and bleeding relevant among those engaged in recommended level of among those not engaged in recommended level of variables gender, race, variables of atrial body mass medical history of chronic disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and = hazard PA = physical variables gender, race, variables of atrial body mass medical history of chronic disease, coronary artery disease, diabetes mellitus, heart failure, hypertension, myocardial infarction, peripheral vascular disease, kidney disease, stroke, and in a = hazard PA = physical In our study following 1,244 older adults with AF, we that patients meeting the guideline-recommended level of PA had mortality, our is with previous A retrospective study patients AF with that was associated with lower of all-cause E Lane DA and all-cause mortality among patients with atrial Am Heart 2021; Scopus Google Scholar is because of the large number of patients However, we are more in the PA level because we used a questionnaire. In the Research on AF which included patients with AF, higher level of PA by per was shown to be associated with a lower mortality risk 1 of M G C G L Lane DA physical activity and major adverse events in patients with atrial fibrillation: a report from the Research Survey on atrial fibrillation 2017; PubMed Scopus Google Scholar study involved patients aged years from the of the Health Study The on PA using the Health Study 1 questionnaire and the based on guideline-recommended level of that participants who met the recommended lower mortality than the and those did not the recommended PA H and cardiovascular outcomes in with atrial fibrillation: the Heart J. 2020; PubMed Scopus Google Scholar with 2 our study is more on the geriatric AF the aged ≥65 years were and health care providers should the recommended level of PA in the of patients with AF and patients of the of meeting the recommended level of PA on mortality, association was with stroke or bleeding (i.e., major bleeding and clinically relevant in our study. In 1 study including participants on anticoagulation for patients who were more were to experience less major bleeding. In the indication of anticoagulation in our study is AF, and we were more in of PA of using with 4 we used a validated M A K HJ B M M M J A M M CM activity and risk of bleeding in patients Thromb Haemost. 2015; PubMed Scopus Google Scholar In study including participants from the was between PA and ischemic stroke, but is report on stroke among the AF M A A M C and risk of coronary artery disease, myocardial and ischemic a Cardiol. 2021; PubMed Scopus Google Scholar A including that participants engaging in PA lower risk of ischemic and stroke activity and stroke a 2003; PubMed Scopus Google Scholar between our study and previous be to the cohort of older adults with AF, and clinical characteristics, used to and the of should examine the of recommended of PA on bleeding and stroke among older adults with AF over a of In it is that patients with risk factors for mortality to engage in regular PA than the engagement of activity mortality we adjusted for clinical factors shown to be with mortality among adults with M B A J J J M S C J A C associated with in patients with atrial fibrillation: an the J Med. 2021; Full Text Full Text PDF PubMed Scopus (1) Google SR G W RM AF Committee and AF Committee of death and of all-cause mortality in patients atrial fibrillation: data Am Heart PubMed Scopus Google Scholar be factors that mortality risk and the to exercise those examined in study. to promote PA among older adults with AF who engage in regular exercise on whether PA in However, the data the physical and health of J. Cardiology patient pages. Exercise and cardiovascular health.Circulation. 2003; 107: e2-e5Crossref PubMed Google Jr, JB. The association of in level and other characteristics with mortality among J Med. PubMed Scopus Google SJ BE Swartz AM Heart Committee of the on and Health and and Committee of the on and to the of physical activity: clinical and research a from the Heart 2013; PubMed Scopus Google A interval the burden of atrial fibrillation in the a PubMed Scopus Google Carlson SA Galuska DA A Fulton JE among adults aged years and older PubMed Scopus Google HJ with physical activity in patients with and cardiovascular Heart J. 2019; PubMed Scopus Google Scholar we activity in population is study has several we used data from a large cohort of older adults with AF, with and demographic and clinical we used the Minnesota Leisure Time PA to which is a validated and SJ BE Swartz AM Heart Committee of the on and Health and and Committee of the on and to the of physical activity: clinical and research a from the Heart 2013; PubMed Scopus Google Scholar to the of our study is among the to whether guideline-recommended level of PA clinical outcomes in patients with AF over a of 2 study also has the of participants as non-Hispanic the of our to adults of other it is that participants their engagement in in 19 participants experienced a stroke the 2-year follow-up, for the association between PA and should be with ME Leon Seeman G to in older J PubMed Scopus Google Scholar In conclusion, our study that older adults with AF who engage in the recommended level of PA were less likely to than adults who were less over 2 years of stroke, major bleeding, and clinically relevant bleeding did not between However, PA has been shown to health mortality, as cardiovascular risk AF symptoms and arrhythmia and should encourage guideline-recommended including an exercise and in the for older adults with AF. 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