Key takeaways
Despite guideline recommendations, exercise-based rehabilitation is underused in patients with atrial fibrillation (AF).
In the NEXAF trial, a one-year tailored exercise programme significantly reduced time in AF compared with usual care.
Significant improvements in quality of life were not observed, although the exercise intervention improved cardiorespiratory fitness and reduced hospitalisations.
The intervention, which combined short-term supervision with long-term home-based exercise, was feasible in clinical practice and may allow broader implementation of exercise-based rehabilitation.
Munich, Germany – 30 August 2026: An exercise programme combining short-term supervision with long-term home-based exercise was associated with reduced atrial fibrillation burden and other meaningful benefits, according to results presented in a Hot Line session today at ESC Congress 2026.1
While the incidence of some cardiovascular diseases is stable or decreasing, atrial fibrillation (AF) prevalence is rising.2 Although lifestyle changes and risk factor modification are acknowledged as central components of AF management, tailored exercise remains underused. Principal Investigator of the NEXAF trial, Doctor Bjarne Nes from the Norwegian University of Science and Technology, Trondheim, Norway, noted: "Despite recommendations in ESC Guidelines,3 there is currently an implementation gap – only around 1 in 10 eligible patients are being referred for exercise-based rehabilitation according to a survey from the European Heart Rhythm Association.4"
Doctor Nes also pointed out a knowledge gap: "The few trials that have been published evaluating exercise are mostly short-term, small-scale studies where AF burden has not been continuously monitored." The NEXAF trial was designed to evaluate the effects of a one-year exercise intervention in reducing the total AF burden and improving AF-specific quality of life (QoL) in symptomatic patients with AF.
The trial was conducted at three centres in Norway and enrolled patients with non-permanent AF and physical activity levels below general recommendations. Patients were randomised (1:1) to a one-year exercise intervention or usual care. The exercise intervention consisted of eight supervised high-intensity sessions during the first four to six weeks, followed mainly by remote exercise monitoring and guidance using a smartwatch, app and a web-based platform. Usual care involved no structured or supervised exercise programmes. An insertable cardiac monitor was implanted in all participants. The co-primary endpoints were time in AF as a percentage of total time monitored (AF burden) during the one-year follow-up and change in the Atrial Fibrillation Effect on Quality of Life (AFEQT) questionnaire overall score at one year.
The trial population included 295 patients who had a mean age of 64 years and 30% were women.
The researchers found a 45% relative reduction in the co-primary endpoint of AF burden in patients assigned to the exercise intervention vs. usual care at one year (3.9% vs. 7.1%, respectively; p=0.016). Despite the improvement in AF burden, there was no significant difference in AF-specific QoL with the exercise intervention at one year (AFEQT score: +5.6 vs. +4.4; p=0.43).
Regarding secondary endpoints, improvements were observed in measures of cardiorespiratory fitness and resting heart rate with the exercise intervention. The researchers also observed a 37% reduction in total hospitalisations and a 46% reduction in AF-related hospitalisations.
Summing up the findings, Doctor Nes said: "In this large, randomised trial, a one-year exercise intervention induced a meaningful reduction in total AF burden, improved fitness and led to fewer AF-related hospital admissions compared to usual care." He noted that the hybrid model combining short-term supervision with long-term home-based exercise and digital support was delivered with modest personnel resources and was clinically feasible. "The trial strengthens the arguments for broader implementation of structured, long-term exercise in AF care," he concluded.
The first dedicated ESC Guidelines on cardiac rehabilitation were published recently in the European Heart Journal.5
