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A 57-year-old male with atrial fibrillation and reduced ejection fraction: correct dose of exercise prescription

Sabiha Gati, Sports Cardiology Quiz Section Editor

Atrial fibrillation (AF) associated with heart failure (HF) increases patients' physical inactivity, worsening the clinical condition and exercise intolerance, increasing the risk of hospitalisation, with loss of independence and worsening of quality of life. To break this vicious circle, physical activity should be stimulated in these patients, as long as they are clinically stable, on optimised clinical treatment, using beta-blockers and with a resting heart rate < 80 bpm and < 110% of the predicted for their maximum exercise age.

This quiz highlights the effects of supervised exercise training guided by the Borg scale on physical capacity, neuromuscular sympathetic activity and muscular blood flow in a patient with AF associated with HF and reduced ejection fraction.

Rehabilitation and Sports Cardiology

The case

  • A 57-year-old male was diagnosed with non-ischemic dilated cardiomyopathy associated with long standing permanent atrial fibrillation (AF). On presentation he was in New York Heart Association functional class III. On clinical examination, the heart rate was 75 bpm with a blood pressure of 115/80 mmHg. The chest was clear and there was no peripheral oedema. Cardiac auscultation revealed dual heart sounds with no additional murmurs.
  • Associated co-morbidities: non-insulin-dependent diabetes mellitus and body mass index of 36.8 kg/m2, grade II obesity.
  • The patient was on the following medical therapy: Losartan 100 mg od, Furosemide 40 mg od, Carvedilol 150 mg od, Warfarin according to INR, Simvastatin 20 mg od, Metformin 850 mg bid and Omeprazole 20 mg od.
  • Echocardiography demonstrated a left ventricular ejection fraction was 35% (Simpson method), with diffuse myocardial hypokinesis, left ventricular diastolic dimension of 57mm, left atrial size of 54 mm. The right ventricular size was 37 mm (basal segment) with preserved systolic function. Pulmonary artery systolic pressure measured 35 mmHg. There were no significant valvular abnormalities.
  • Cardiopulmonary exercise testing showed a VO2peak 14.7 mL/Kg/min and a VE/VCO2 slope 33


Test your knowledge


Case report

Read the corresponding case report:

Atrial fibrillation in heart failure with reduced ejection fraction: a case report of exercise training
Guilherme Veiga Guimarães, et al.

European Heart Journal - Case Reports, 15 October 2020, ytaa364, 

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Note: The views and opinions expressed on this page are those of the author and may not be accepted by others. While every attempt is made to keep the information up to date, there is always going to be a lag in updating information. The reader is encouraged to read this in conjunction with appropriate ESC Guidelines. The material on this page is for educational purposes and is not for use as a definitive management strategy in the care of patients. Quiz material on the site are only examples and do not guarantee outcomes from formal examinations.

Notes to editor

Author information:
Prof. Guimaraes, Guilherme V. University of Sao Paulo - Brazil