Super-Rehab: a Novel Approach to Reverse Atrial Fibrillation

The "Super Rehab: a novel approach to reverse atrial fibrillation?" study proposes to test the use of a novel lifestyle intervention (Super Rehab), in addition to standard care, for patients with symptomatic atrial fibrillation (AF) requiring rhythm control strategy who are overweight.

As the main driver behind the selection of a rhythm-control strategy for patients with AF, the primary outcome will be an improvement in AF-related symptoms with Super Rehab versus Usual Care only. Key secondary outcomes will include the burden of AF, change in stroke risk, biochemical and cardiac functional and structural changes, and markers of quality-of-life and health economic costs.

In this randomised controlled trial (RCT) the investigators will study the efficacy of a novel lifestyle intervention (Super Rehab), in addition to usual care, for patients with symptomatic atrial fibrillation (AF) where are a rhythm-control strategy is being employed who are overweight. Increasing evidence has shown that AF can respond to robust lifestyle change and aggressive risk factor modification, and in some case can in fact regress.

In the majority of cases, the decision to target a rhythm-control strategy for AF is based on the symptom-burden reported by the patient. This in light of the low volume of evidence suggesting any benefits of rhythm-control strategies over rate-control strategies based on prognostic clinical outcomes.

The modifiable cardiovascular (CV) risk factors that increase both CV risk and the frequency of its various forms of disease also impact the development and progression of AF. In addition, patients with multiple CV risk factors are at enhanced risk of both poorer long-term outcomes and earlier failures of traditional rhythm-control strategies.

This RCT study will involve patients who have described symptomatic AF such that their treating team have elected a rhythm-control strategy (i.e. a combination of anti-arrhythmic therapy ± a referral for a direct current (DC) cardioversion and/or an ablation) who are also overweight (body mass index \[BMI\] ≥27kg/m2). The BMI criterion acts as a marker of CV risk that may respond to a lifestyle intervention, which has proved sensitive in other studies.

Participants will be randomised to either Super Rehab and Usual Care or to continue Usual Care only. Super Rehab includes a combination of 1:1 supervised high-intensity exercise, dietary advice sessions and 3-monthly clinical reviews to optimise CV risk factor management. The whole programme lasts 12 months. Participants in both arms will undergo imaging, fitness, clinical tests (including blood tests), and complete questionnaires on four occasions during the study.

The primary outcome of the study will assess the difference in AF symptom burden between the two groups. In addition, the study will assess important secondary outcomes that include change in AF burden (i.e. the amount of time spent in AF), stroke risk, quality-of-life and well-being, biochemical, anthropometric, blood pressure and cardiac functional and structural changes, and a cost-effectiveness analysis.

Eligibility Criteria:
Inclusion Criteria:

* Aged \>18
* Symptomatic AF (paroxysmal or persistent \<12-months) with a rhythm control management strategy selected including consideration of referral for a cardioversion or ablation forming part of their planned pathway
* BMI ≥27m/kg2

Exclusion Criteria:

* Prognostic coronary artery disease, defined as left main stem \>50% stenosis or ≥ moderate disease in ≥3 major epicardial vessels
* Unstable angina
* New York Heart Association class III/IV heart failure or severe left ventricular impairment
* Significant cardiomyopathy (as assessed by Cardiologist, e.g. hypertrophic cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy)
* Severe heart valve disease
* Severe hypertension (BP \>180/120mmHg) despite optimising anti-hypertensive therapy
* Uncontrolled arrhythmia or higher degree heart block
* History of aortic dissection
* Recent acute pulmonary embolus, deep vein thrombosis, stroke or transient ischaemic attack
* Severe autonomic or peripheral neuropathy
* Acute systemic illness of fever
* Significant acute or chronic renal failure
* Pulmonary fibrosis or interstitial lung disease
* Physically unable to participate in high-intensity exercise
* Pregnancy
* Prior atrial fibrillation ablation
* A clinically significant ECG abnormality at the screening visit, which in the opinion of the investigators exposes the subject to risk by enrolling in the trial
* Participation in another intervention-based research study
* Inability to fully understand the instructions provided during the study