The key points to remember from this American Heart Association Scientific Statement about lifestyle and risk factor modification for reduction of atrial fibrillation (AF) are the following:

1. Animal experiments indicate that increasing weight correlates with increased biatrial volumes, inflammatory infiltrates, transforming growth factor-β1 (TGFβ1), platelet-derived growth factor (PDGF), fibrosis, heterogeneity of activation and conduction velocity slowing, rate-dependent conduction slowing, spontaneous AF episodes, easier AF induction, and longer AF episodes. Obesity-related hypertension and diastolic dysfunction can also activate stretch-activated left atrial channels, increasing AF susceptibility.
2. In the LEGACY trial, patients underwent goal-directed weight loss and risk factor management over 4 years. Patients who lost and maintained the loss of >10% of their bodyweight had a six-fold increase in freedom from AF compared with those who lost <3% of weight.
3. Bariatric surgery may produce benefits in reduction of AF risk. In the Swedish Obese Subjects cohort study of 2,000 obese subjects who underwent bariatric surgery were matched to 2021 obese control subjects; risk of new AF was 29% lower in the surgery group with more risk reduction in younger subjects and those with higher blood pressure.
4. A paradoxical effect of very low body weight on increased risk of AF has been noted.
5. Regular aerobic exercise is effective in reducing AF burden and improving AF-related symptoms and quality of life. CARDIO-FIT, a cohort study, assessed the impact of cardiorespiratory fitness gain on AF burden in overweight and obese individuals with nonpermanent AF. Higher cardiorespiratory fitness and a gain in cardiorespiratory fitness over time were associated with a greater reduction in AF burden. Improvements in exercise capacity as small as ≥2 METs in overweight individuals on top of weight loss were associated with a twofold greater freedom from AF.
6. Excessive exercise, such as that undertaken by endurance athletes, may increase AF risk. A meta-analysis showed that athletes had a fivefold increased risk of AF compared with age-matched controls. Further research is needed to determine whether a longer duration of high-intensity interval training (HIIT) remains beneficial in reducing AF burden or risk or whether it may paradoxically induce the electric changes thought to cause AF in endurance athletes. Moderate exercise at doses recommended by the 2018 Physical Activity Guidelines Advisory Committee (150 minutes/week of moderate-intensity exercise) does not increase the risk of AF.
7. Multicomponent exercise (aerobic exercise, muscle strengthening, and balance training) and mind-body exercises such as yoga and tai chi may help in the management of AF. In YOGA My Heart Study, 3 months of yoga training reduced AF burden and symptoms and improved several domains of quality of life. The presumed mechanism is via salutary effects on cardiac autonomic function.
8. There is a high prevalence of sleep-disordered breathing (SDB) in patients with AF. Observational evidence suggests a dose‐response relationship between SDB severity and AF incidence, burden, and response to treatment. Patients with SDB who receive therapy with continuous positive airway pressure (CPAP) appear to have a lower risk of AF recurrence after AF ablation. Randomized trials of screening and treatment for SDB for patients with AF have not been published.
9. Diabetes mellitus (DM) is associated with a higher risk of AF. Glycemic control has been associated with reduced risk of AF. Blood sugar control may be an important strategy to reduce recurrent AF burden.
10. Hypertension is associated with risk of developing AF. Blood pressure management for AF follows current guidelines for general cardiovascular health and should include lifestyle factors (obesity, physical inactivity, and diet) and pharmacotherapy.
11. Given the importance of risk factor modification in AF management, and the low implementation rate of those measures, an integrated care approach may facilitate intensive and comprehensive lifestyle counseling. A randomized controlled trial showed that a multidisciplinary, integrated, protocol-driven, guideline-based clinic resulted in a 35% relative risk reduction of the composite endpoint of cardiovascular hospitalization and mortality in patients with AF.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Diet, Exercise, Hypertension, Sleep Apnea

Keywords: Arrhythmias, Cardiac, Athletes, Atrial Fibrillation, Bariatric Surgery, Blood Glucose, Blood Pressure, Diabetes Mellitus, Diet, Exercise, Exercise Tolerance, Exercise Therapy, Fibrosis, Hypertension, Life Style, Obesity, Overweight, Platelet-Derived Growth Factor, Primary Prevention, Quality of Life, Risk Factors, Risk Reduction Behavior, Sleep Apnea Syndromes, Thinness, Transforming Growth Factors, Weight Gain, Weight Loss, Yoga

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