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“Here we offer handy hints and tips for maintaining good heart health, including what to eat, how to exercise and the importance of managing your stress levels. These all really do help to keep atrial fibrillation (AF) under control, I hope it is helpful.”Nick Mills - Cardioversion and Cardiac Rehabilitation Specialist Nurse, Addenbrooke’s NHS Trust, Cambridge

Nutrition and diet

Nutritional Therapist, Caroline Skirrow (thefoodfixer) has put together dietary advice to help people with AF to reduce their risk of AF-related stroke. Caroline has over 10 years experience in nutrition, helping to improve healthy eating habits of her patients in liaison with their HCP.

You may be aware that eating a healthy diet is good for reducing your risk of heart disease but did you know that it can also be of benefit even if you already have heart disease?

As someone with AF there are a number of AF-related stroke risk factors that you can reduce by eating a healthy diet. For example, eating the right diet can:

  • Help lower your blood pressure
  • Help reduce your cholesterol
  • Help you control your weight
  • Help reduce the risk of other conditions such as diabetes1

This guide is designed to help you understand the basic principles of healthy eating with tips and examples of things that you can follow to improve your health. There are also examples of some specific foods that evidence has shown are particularly 'heart healthy'.

What are the basic principles of a healthy diet?

A healthy diet should:2

  • Be high in starches, but low in sugars and refined carbohydrates
  • Be high in vegetables
  • Contain moderate amounts of fruit
  • Contain small amounts of good fats in the right balance
  • Keep you well hydrated
  • Contain moderate amounts of healthy proteins, including fish, nuts and dairy products
  • Be low in salt, alcohol and caffeine
  • Contain plenty of fresh and unprocessed foods

The Government 'eatwell' plate below illustrates how these different elements can be balanced in your daily diet.3

Let's take each one of the sections on the eatwell plate and look at them in more detail to:

  • Explain why they are important
  • Provide you with more specific guidance on how much to choose from each group
  • Show you what that looks like in terms of real food examples
High in starches but low in sugars and refined carbohydrates
Why?

Our diets have become very high in processed foods high in sugars and refined carbohydrates. This means that we can be consuming a very high calorie intake whilst actually being quite low in vital nutrients. High consumption of these quick energy release foods can contribute to unstable energy levels and weight-gain.4

By choosing less refined forms of carbohydrate such as whole grains, beans and starchy vegetables we draw the energy from these foods more slowly. This helps stabilise to our blood sugar and give us more consistent energy levels. The slower energy release also means we feel fuller for longer aiding weight management.

Less processed sources of carbohydrate are also rich sources of vitamins and minerals vital for supporting our overall health. They are also high in different types of fibre which are important for a healthy gut function and the removal of toxins from the body. Oats and beans are particularly high in something called soluble fibre which can help reduce your cholesterol levels.5

Avoid

Simple carbohydrates: sugar, syrup, corn-fructose syrup, excess fruit juice, honey, cordials, soda, sweets, puddings, sweetened jams, chutneys, sweetened canned fruit.

How much?

Under 90g per day. If you have diabetes sugars it will have a major impact on your blood glucose so you should be aiming to keep processed sugars to a minimum.6

What does it look like?

There are 20g of sugar in:

  • 1 medium apple
  • 1 small glass (200ml) of orange juice
  • 4 teaspoons of sugar
  • 4 chocolate digestives
  • ½ a can of fizzy drink
  • 1 medium bowl of tinned tomato soup
Limit

Refined carbohydrate: white flour products (bread, pasta, pastries, noodles, couscous, cakes, biscuits, crackers), processed potatoes (crisps, mash, gnocchi), white rice.

Choose instead

Slow burning carbohydrate:

Grains: Wholemeal bread, whole what pasta, rye bread, rye crisp bread, brown rice, pearl barley, wholegrain cereals, porridge, oatcakes, quinoa.

Beans: Pinto, butter, flageolet, soya, kidney, cannellini, adzuki, chick peas, lentils, split peas, baked beans, daal, hummus, gram flour, low-salt baked beans.

Starchy vegetables: Potatoes, plantain, sweet potatoes, carrots, parsnips, beetroot, swede, broad beans, peas.

How much?

230g per day for women. 300g for men.

What does it look like?

There are 50g of carbohydrate in:

  • 3 slices of brown bread
  • 75g of uncooked pasta or oats
  • 65g of uncooked rice
  • 300g of potatoes
  • 1 tin of beans
  • 500g of vegetables e.g. carrots, broad beans, peas, broccoli
High in Vegetables
Why?

Vegetables are low in calories and high in vitamins, minerals, fibre and other plant based chemicals that protect our health.7

Examples

Aubergine, artichoke, beetroot, broad beans, broccoli, cauliflower, celery, carrots, coriander, courgettes, green beans, kale, leeks, lettuce, mushrooms, onion, peppers, parsnips, parsley, peas, rocket, runner beans, spinach, squash, sweet corn, sweet potato, tomatoes, watercress.

How much?

A portion is 80g. Aim for at least 3-4 portions per day in a variety of colours.

Moderate amounts of fruit
Why?

Fruit is higher in sugar than vegetables, so although it contains high levels of protective vitamins and minerals if you have all of your 5-a-day as fruit you will be consuming quite high levels of sugar. Processed fruit products such as jams, juices, pie fillings and puddings are often naturally higher in sugar or have added sugar so opt for fresh fruit where possible and read the label on any processed product.

Examples

Oranges, satsumas, lemons, apples, pears, all berries, stone fruits (peaches, nectarines, apricots, cherries), kiwi fruit.

Some fruits release their sugars more quickly than others so if you are watching your weight moderate your intake of banana, melon, grapes, and mangos in favour of the slower release fruits above.

How much?

A portion is 80g (3oz). Aim for at least 2-3 portions per day in a variety of colours.

The right fat balance
Why?

We need to eat some fat to run vital processes in the body and to absorb some vital nutrients. However, fat is highly calorific so it is important to keep the total quantity under control and to try and keep a healthy balance between the different types of fat.

The Mediterranean Diet has been shown to reduce risk factors for heart disease and includes moderate levels of the omega-3 and omega-9 fats in combination with reduced saturated fat and omega-6 intake and avoidance of trans and hydrogenated fats which are heavily processed and often used in cheaper processed foods.8

As lots of foods contain natural fat (e.g. meat, fish, dairy, nuts and some vegetables) be aware of how much food you have from these sources and be careful adding extra fat to meals. Trim fat from meats, moderate full fat dairy intake and use spreads and oils sparingly in food preparation. When buying processed foods be sure to check the label.

Fats to avoid

Saturated fats rich: full-fat diary products, meat fats, processed meat products e.g. bacon, salami, corned beef.

Trans and hydrogenated fats: used in commercial frying and in many pre-packaged food.

Overheated fats: Any fat that has been exposed in high temperatures such as deep fried foods.

Fats to limit

Omega-6 rich: Safflower, sunflower, grape seed, corn, soya, sesame, spreads, dressings and products make with these oils such as baked goods.

Fats to choose

Omega-3 rich:

Oily fish: salmon, trout, anchovy, fresh-tuna, mackerel, herring, sardines, Cornish sardines.

Nuts and seeds: hemp, flax (linseeds), walnuts and pumpkin seeds (and their oils).

Omega-9 rich: Olives, avocados, almonds, cashew nuts and their oils, canola oil.

Guidelines

Women

Men

Total fat

70g

95g

Saturated Fat

20g

30g

Unsaturated Fat

50g

60g

How much?

There are 20g of unsaturated fat in:

  • 220g of salmon (2 fillets)
  • 50g of nuts (a handful)
  • A tablespoon of olive oil
Moderate amounts of lean protein
Why?

Protein is important for running our metabolism and for building and repairing the structure of the body. It also helps us feel full9 so eating adequate protein can help you control your appetite and contribute to weight management.

Proteins to limit or avoid

Processed meats which are high in salt, fat and additives e.g. bacon, ham, salami, corned beef, spam.

Proteins to choose
  • Lean poultry (e.g. chicken, turkey)
  • 2-3 servings per week of fish and seafood especially oily fish (salmon, trout, mackerel, tuna, sardines, pilchards)
  • Eggs
  • Pulses (e.g. chickpeas, lentils, beans
  • Unsalted nuts and seeds
  • Soy products (e.g. tofu, soy milk / yoghurt)
  • Low fat dairy products (e.g. cottage cheese, unsweetened low fat yoghurt, ricotta)
How much?

The guideline daily amount of proteins for a woman is 45g and for a man is 55g.

What does that look like?

You would get 10g of protein in:

  • Half a salmon fillet (40g)
  • Half a tin of beans (200g)
  • 2 small eggs
  • 2 heaped desert spoons of cottage cheese
  • A moderate handful of almonds (50g)
Well hydrated
Why?

Dehydration is very common and even mild dehydration can contribute to symptoms of fatigue, poor concentration and memory. If you have AF then staying hydrated is really important as dehydration can also affect heart rhythm and increase your blood pressure.10

Caffeine is a stimulant and can affect heart rate so it is advisable to keep your consumption under control.11 It is also a diuretic so can contribute to dehydration, so should be consumed in moderation.

Examples

Water, decaffeinated or herb teas or watered down fruit juices and weak fruit cordials, milk. Wet foods such as soups and stews also count towards your hydration.

How much?

Consume 6-8 medium glasses (1 to 2 litres) of fluid per day

Limit your alcohol intake
Why?

Drinking more than the government guideline amount elevates your risk factors for AF-related stroke by causing damage to the heart muscle, affecting heart rhythm and increasing blood pressure.12

How much?

Guidance for women is no more than 14 units per week
Guidance for men is no more than 21 units per week

The number of units is based on the size of the drink and its alcohol strength, one unit of alcohol is:

  • A small glass (100ml) of average strength wine
  • Half a pint (about 300ml) of normal strength beer or cider
  • A single measure (25ml) of spirits (40% ABV)
  • A small glass (50ml) of sherry or fortified wine (20% ABV)
Use alternatives to salt to season food
Why?

Excess salt can cause fluid retention which may cause swelling and exacerbate high blood pressure.13 Be aware that your salt intake is not just the salt you add to your food.

Pre-packaged food is often very high in salt, even foods you wouldn’t expect like sweet biscuits, cakes and cereals. Be sure to read food labels carefully so that you are aware of your intake and keep it below the recommended intake.

How much?

5g per day for women. 7g per day for men.

Examples

Use a potassium based salt e.g. Lo-Salt or season food with fresh and dried herbs, spices, garlic, mustard, horseradish or vinegar instead.

Getting started

Making changes can be daunting even if you know you are going to get benefits in the long run, so take it one step at a time. That way the change will be easier to manage and you are more likely to sustain the new healthier pattern over the long-term. Try the steps below:

  1. Keep a food diary for a week so you can realistically assess your diet
  2. Pick an area where you think it is particularly weak and set yourself a goal to make an improvement
  3. Make sure the goal is realistic and achievable and set yourself a timescale to reach it. Make a note of why you are setting the goal and why it is important for you to achieve it
  4. Plan how you will achieve your goal
  5. Tell your friends and family or colleagues about your goal and why it is important for you so they can help support you in making the change
  6. When you achieve your first goal and are comfortable that you can stick with it as part of a way of life go back to step 2) and find a new area to improve

Eating well - top tips

  • Take time to plan ahead - For example pick a time at the weekend when you can plan your meals and shopping so you can always have healthy choices to hand (use the suggested weekly food planner to help you).
  • Get a really simple recipe book with quick, easy and healthy options or check online if you use a computer or tablet.
  • If you are buying packaged food ALWAYS read the label. See the 'Food Labelling' section below for guidance. Keep a particular eye on your salt, sugars and saturated fat content to help you stay within healthy limits.
  • If you are trying to manage weight think about:
    • Weighing portions to help with portion control.
    • Using standard sized crockery and not overloading your plate.
    • Adding high volumes of vegetables to your meals to fill you up as they are very low in calories and very high in protective nutrients and fibre.
  • Avoid keeping unhealthy items at home For example, salted snacks, cakes and biscuits. If they are not there, you can not eat them.
  • If you have a freezer, then try making your own healthy ready meals - Cook larger batches of food and weigh out sensible portions and freeze them.
  • If you are unable to cook look for pre-cooked chicken and fish in the supermarket which you could add to a healthy salad packed with different ingredients.
  • If you have not cooked or do not feel confident cooking then just experiment! - Cooking is very creative and can be great fun, so do not be scared of giving it a go.
  • If you have a sweet craving try fresh or dried fruit, or a small chunk of dark chocolate to see if you can avoid raiding the biscuit tin.
  • Dehydration and hunger can feel very similar so try a glass of water and see how you feel before you decide you need to eat.
Heart 'helpful' foods
Foods What is in it? Why is it helpful?
Oats, beans, lentils, whole grain cereal products, soy products

Soluble fibre

Helps reduce cholesterol

Chicken, turkey, fish, whole grains (oatmeal, wheat germ, brown rice), eggs, vegetables, soya beans, peanuts

B6

Preventing deficiency by ensuring adequate levels in the diet helps to lower the risk of heart conditions

Broccoli, Brussels sprouts, spinach, asparagus, peas, chickpeas, brown rice, liver

B9 (Folate)

Preventing deficiency by ensuring adequate levels in the diet helps to lower the risk of heart conditions

Salmon, cod, dairy products, eggs, meat, some fortified breakfast cereals

B12

Preventing deficiency by ensuring adequate levels in the diet helps to lower the risk of heart conditions

Low fat dairy products, soy products, nuts and seeds (especially sesame seeds), bones of cooked fish e.g. tinned sardines

Calcium

Diets high in calcium and potassium are associated with reduced blood pressure

Bean, green leafy veg, carrots, mushrooms, bananas, avocado, salmon, potatoes

Potassium

Green leafy vegetables, nuts and seeds

Magnesium

Magnesium deficiency is associated with increased risk heart rhythm issues and incidence of AF14

Avocados

Plant sterols

Help reduce cholesterol15

Green tea

Antioxidants

Help reduce cholesterol

Garlic

Allicin

Help reduce cholesterol

Unsweetened cocoa solids (in moderation) e.g. good quality 95% chocolate

Antioxidants

Can help lower blood pressure and reduce atherosclerosis and thrombosis risk

Warfarin - diet considerations

If you are taking warfarin you may need to modify some of the foods you eat. Warfarin works by interfering with how the liver uses the vitamin K that we get in our diet. This means its effect is altered depending on how many vitamin K rich foods you eat in your diet and how much this varies.

If your dietary intake of vitamin K is reasonably consistent then your warfarin dose will have already been adjusted to match this. If you change the level of vitamin K rich foods in your diet you will need to discuss this with your doctor as the effectiveness of your warfarin will be affected.

Foods high in vitamin K Foods low in vitamin K
  • Asparagus
  • Green beans
  • Blackberries
  • Blueberries
  • Broccoli
  • Brussel sprouts
  • Cabbage
  • Chicory
  • Collard greens
  • Cranberry juice
  • Kale
  • Kiwi fruit
  • Lettuce
  • Mungo beans
  • Peas
  • Pine nuts
  • Raisins
  • Sugar snap peas
  • Soybeans
  • Spinach
  • Swiss chard
  • Watercress
  • Apples
  • Banana
  • Beef
  • All cereals (including flour, etc.)
  • Cranberries
  • Chicken
  • Cranberries
  • Fish
  • Lamb
  • Lemons
  • Melon
  • Orange
  • Peach
  • Pork
  • Shell fish
  • Strawberries
  • Tofu

Novel oral anticoagulants (novel OACs) - such as apixaban, dabigatran and rivaroxaban - have no food interactions.

If you are taking multiple medications follow the pack guidance or check with your doctor for any food restrictions or interactions, for example, people on statins should avoid grapefruit products.

Weekly meal planner

This planner is intended as a guide to help you understand what a healthy eating plan looks like and where you might need to make some adjustments to your own diet.

Where recipes have used ingredients high in Vitamin K a stamp is included to alert those taking warfarin to check against the table provided above. Ingredients can be removed or replaced with different ingredients.

You can view, and print off, the meal planner from here

Management of stress and anxiety

A small but significant percentage of people with AF experience severe impairment of their quality of life including daily activity, work life, sex life, physical activity, psychological well-being, and social activity and one-third of all people with AF suffer from depression or anxiety.16

Anxiety can trigger an AF episode, and knowing that you have an irregular heartbeat can trigger anxiety — it is a cycle that may actually worsen AF. So it is important to address stress and anxiety to keep it from affecting your AF.

It is natural to feel a little nervous when you are told you have AF but you can take control of your AF management and overcome your anxiety. Anxiety may worsen if you do not really know what is happening with your health, so take an active role in your treatment and management plan. It is essential to talk to your healthcare professional about your concerns and tell him or her about your anxiety. You can work together to manage both your anxiety and your AF. Managing anxiety through the use of medications, exercise, support groups, or mental health professionals can help reduce episodes of uncontrolled AF. Below is a list of other things which may help.

Find what helps you manage stress

Getting stress under control can help with AF and anxiety, but you've got to know what works for your body. You may find that exercise helps or it may be relaxing and reading a book or watching a favourite movie. Having one or two things you know you can do to help manage anxiety during stressful periods is an important goal.

Get quality sleep

Poor sleep may trigger AF and may also worsen your anxiety about AF. Try these simple tips for a good nights sleep:

  • Go to bed and wake at the same time each day
  • Avoid stimulating activities before bed
  • Create a soothing sleep environment
  • Cut out or reduce caffeine

Relaxation techniques

When you are relaxed, your body responds positively. Your blood pressure lowers, your breathing slows, and your sense of well-being improves. If you feel anxious, try to imagine yourself in a peaceful environment. Deep-breathing exercises, in which you focus on long, slow, deep, and regular breaths, may also help relax and soothe you during an episode of anxiety.

Make the effort to exercise

Exercise is especially helpful for managing AF and its associated anxiety. Getting regular exercise can help improve your mood and help you get a good night's sleep. Exercise also helps with stress management, which is a likely AF trigger for many people. Weight loss is an added benefit.

Cognitive Behavioural Therapy (CBT)

People respond in different ways to AF, for some it may be helpful to have psychological therapy which has often been shown to be beneficial for many long term conditions.

CBT is a treatment that can help people feel better in themselves and adjust to their diagnosis of AF. It supports a self-management approach to coping with a condition and uses tried and tested methods. CBT has been found to be one of the most effective treatments for conditions where anxiety, frustration and depression are significant problems.

“Relieving stress, transforming lives” Improving Access to Psychological Therapies (IAPT) is an NHS programme rolling out services across England offering interventions approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety disorders.

CBT is a talking treatment directed at the ways you respond to and cope with present difficulties. It is based on understanding the impact of particular situations on what we think, on what we do (or avoid), our physical feelings and our emotions. Anxiety due to AF might lead you to worry about experiencing an AF episode whilst away from your ‘safe’ environment, such as while shopping, travelling or at work. This can then lead to rising concern about possible consequences and can set off adrenaline driven symptoms such as a racing heart and faster breathing, which in turn can leave you feeling dizzy or unwell. A vicious cycle develops which can make you feel worse and result in frustration and depression.

Ask your healthcare professional for a referral to someone trained in CBT. The British Association for Behavioural and Cognitive Psychotherapies has a register of accredited CBT therapists. There may also be some self-help books on CBT approaches to coping with physical illness available from your GP.

Sex and relationships

People who have experienced heart problems can often worry about having sex. We know that people often reduce or stop having sex because they are frightened it may bring on further heart problems. However, for most people with all sorts of heart problems (including AF), having sex is safe and indeed recommended by doctors!

Think of it this way, for the average person, male or female, having sex puts the same amount of work on the heart as a steady 20 minute walk. Having an orgasm is the same as walking up some stairs.

The bottom line is that exercise is good for the heart and sexual activity is just another form of exercise. So – opposite to certain worrying thoughts and fears - regular sexual activity can actually be good for our hearts!

The correct information about sex
Sex has cardiovascular benefits

Sex helps increase blood flow; increased heart rate and deep breathing improves circulation.

Fresh blood supply soaks organs and muscles with fresh oxygen and hormones, and as used blood is removed, so too are waste products.

The exercise of sex lowers cholesterol and more importantly it tips the HDL / LDL (good/bad) cholesterol balance towards the healthier HDL side.

Sex relieves stress

Having sex lowers blood pressure and causes overall stress reduction. Science shows that there is a link between partner hugs and lower blood pressure in women!

Sex boosts the immune system

Having sex has been linked with higher levels of an antibody (called immunoglobulin A) which can protect us from getting colds and other infections.

Sex burns calories

Thirty minutes of sex burns 85 calories or more. Here's how that matches up to other activities that you may have been advised to start: yoga 114 calories per half hour, dancing 29, walking 153.

Sex boosts self-esteem and improves intimacy

We can start to feel better about ourselves and our relationships. Having sex and orgasms increases the levels of a hormone (oxytocin) the so-called "love hormone", which helps us bond and build trust.

Sex reduces pain

As the hormone oxytocin is released, our bodies "natural pain killers" (endorphins) increase, and pain reduces.

Sex reduces prostate cancer risk for men and strengthens pelvic floor muscles for women

Frequent ejaculations have been shown to reduce risk of prostate cancer later in life.

For women, pelvic floor muscle exercises during sex offers two main benefits - Allows greater pleasure and also strengthens the area and helps to minimise the risk of incontinence later in life.

How to do pelvic floor muscle exercises: tighten the muscles of your pelvic floor, as if you are trying to stop the flow of urine. Count to three, then release.

Sex helps you relax more and sleep better

The deep relaxation that typically follows sex may be one of the few times that people actually allow themselves to completely let go, surrender and relax.

The hormone oxytocin released during orgasm also promotes sleep; and getting enough sleep has been linked with a host of other benefits, such as maintaining a healthy weight and blood pressure.

Another common complaint amongst male AF patients is erectile dysfunction (ED), also known as impotence – the inability to get and maintain an erection that is sufficient for satisfactory sexual intercourse.

If you do not feel confident about having sex and/or if you still have any worries or concerns about having sex following a diagnosis of AF, please take a minute to discuss this with your doctor.

The topic of sex can be difficult for patients to talk about but remember that your doctor and nurses are used to talking about these things and in fact would welcome questions to allow you to get the information and advice you need.

ED is a very common condition, particularly in older men. It is estimated that half of all men between the ages of 40 and 70 will have it to some degree.

ED is also a known side effect of beta blockers, which you may have been prescribed to help control your heart rhythm.

A number of treatment options are available for the management of ED and you should discuss this with your doctor if you (or your partner) are experiencing difficulty getting and maintaining erections.

Exercise and AF

Why is exercise important?

Being inactive means our bodies become unfit. This not only means you are more likely to develop poor health related complaints such as heart disease and diabetes, it also means you are more likely to both tire and become short of breath more easily. You may already experience these as symptoms of AF. By improving your physical fitness you can help reduce these symptoms and therefore enjoy life a little more. Taking gentle to moderate levels of exercise is safe for people with AF. In general, ‘if it feels ok it is ok’, but of course there is a little more to it than that.

Regular exercise, especially aerobic exercise, has many benefits. It can:

  • Strengthen your heart and cardiovascular system
  • Improve your circulation and help your body use oxygen better
  • Increase energy levels so you can do more activities without becoming tired or short of breath
  • Increase endurance
  • Lower blood pressure
  • Improve balance and joint flexibility
  • Strengthen bones
  • Help reduce body fat and help you reach and stay at a healthy weight
  • Help reduce stress, tension, and depression
  • Boost self-image and self-esteem
  • Improve sleep
  • Make you feel more fit and healthy

Types of exercise which can be beneficial for people with AF

Cardiovascular or aerobic exercise

This is steady physical activity using large muscle groups such as your legs. Aerobic exercise has the most benefits for your heart. It also strengthens the heart and lungs and improves the body's ability to use oxygen. Over time, aerobic exercise can help your blood pressure and improve your breathing. In other words your heart will not have to work as hard during exercise. Simple examples are walking, cycling and jogging. Anything that increases your heart rate steadily and keeps it raised for a period of time.

Strengthening exercises

These are repeated muscle contractions (tightening). When done regularly they help tone muscles, improve strength, and increase your metabolism. This can be of benefit with activities such a shopping, housework and hobbies such as gardening. Light weights are a good form of strengthening exercises. Resistance bands (like giant elastic bands) are also very useful and versatile. They come in different strengths which are different colours. Be aware that the colours are not universal as each manufacturer uses different colour codes. Ask someone who sells them for advice on which resistance to try first. They should also be able to supply information on how to use them.

How often should I exercise?

In general, you will achieve maximum benefits by gradually working up to an aerobic session of at least 20 to 30 minutes, at least three to four times a week. Exercising every other day will help you start a regular aerobic exercise schedule. The more exercise you can do, the better for your fitness, but any amount of exercise is beneficial to your health and helps ease your symptoms. You can combine aerobic and strengthening exercises or do them at separate times.

What should I include in my exercise programme?

Every exercise session should include a warm-up, a conditioning phase, and a cool-down.

Warm-up

This helps your body adjust slowly from rest to exercise. A warm-up reduces the stress on your heart and muscles, as it slowly increases your breathing, heart rate, and body temperature. The best warm-up includes beginning the activity at a low intensity level and muscle stretching.

Conditioning

This follows the warm-up. During the conditioning phase, more calories are burned, and the main benefits of exercise are gained. The conditioning phase raises your heart rate, makes you feel slightly warmer, breathe slightly faster and possibly perspire lightly. If you experience chest pain, significant breathlessness, or dizziness, you should slow down, stop exercising and let your doctor know about your symptoms.

Cool-down

This is the last phase of your exercise session. It allows your body to gradually recover from the conditioning phase. Your heart rate and blood pressure will return to near resting levels. Cool-down does not mean sit down! In fact, do not sit, standstill, or lie down right after exercise. That could cause you to feel dizzy or light-headed or have heart palpitations (fluttering in your chest). The best cool-down is to slowly decrease the intensity of your activity.

How do I monitor my exercise intensity?

Heart rate monitoring

Exercise effort can be monitored by observing your heart rate and ensuring it does not rise higher than a specific number (target heart rate). For safe and effective exercise it is recommended that you exercise between 60% and 75% of your maximum heart rate. This can be determined by subtracting your age from 220 (estimated max heart rate), and multiplying this by the relevant percentage will give you the region to aim for.

It is important to remember that everyone is different and heart rate targets are very specific to each individual. This is a basic equation and you should be aware that differing levels of fitness and some cardiac medications, including beta blockers may alter your heart rate targets.

For most people the only way of obtaining an accurate target heart rate is by being assessed by an exercise professional who is experienced in cardiac conditions.

Checking your pulse

You can monitor exercise intensity by counting heart beats (your pulse) over one minute. This length of time is important when you have AF due to the variation in your heart rhythm. Taking your pulse by counting your heart beats with your fingers is a very accurate and useful technique to learn. However, when you are exercising it can be impractical to do this. If you do adopt this mode of heart rate monitoring you will usually have to stop exercising which can allow your heart rate to slow reducing the benefits, or can make you feel dizzy. It is therefore essential to keep your feet moving by marching lightly on the spot or tapping your heels. This helps to keep your blood moving back up to your heart.

Many people have trouble finding their pulse. There is a technique to it, so it is best learnt from someone who knows how. A nurse at your GP surgery would be a good person to ask for help.

Electronic Heart Rate Monitors (HRM)

These can be very affordable and are commonly used by people who exercise regularly. They consist of a chest monitor which is attached to the chest with a strap. This picks up an electrical signal which the heart gives off each time it beats. This signal is transmitted wirelessly to a wrist watch unit which then counts the beats and displays it as a number which is your heart rate.

HRMs are sometimes recommended for people with AF as a way of ensuring their heart rate does not go higher than a specific number. However caution is advised as these devices are not recommended for irregular heart rhythms as they can be very inaccurate. Arrhythmias and irregular rhythms are interpreted by the wrist unit as noise or interference which cause them to make error corrections. This often leads to sudden and dramatic changes in the rate displayed which do not represent the true speed of the heartbeat. This can be very worrying and does not help you achieve and maintain a good level of cardiovascular activity. However the blinking heart symbol that is usually seen on the face of the wrist unit will show all heart beats received.

So HRMs work for some people and they can give you some idea of your general level of exercise effort, but you will see lots of numbers going up and down as the unit tries to make sense of your heartbeat. Counting the blinking heart symbol can help to guide you in working out if the displayed heart rate is accurate. If you do decide to try a heart rate monitor you should avoid the cheaper models.

Rating your effort by how you feel

This is the best monitor of exercise effort for people with AF. Working to a 'somewhat hard' level will be closely related to your target heart rate. What makes this easy is that you don’t need to know your target heart rate and you can apply it to any activity you do. However it does take a little practice so you do need to think about it at first.

When participating in any activity it is important that you are able to rate how demanding or strenuous that particular activity is for you. This is called ‘Rating your Perceived Exertion (RPE)’ or the Borg Scale. It is a very good tool for keeping the intensity of your activities safe.

BORG RPE scale
6

No exertion at all

7

Extremely light

8

 

9

Very light

10

 

11

Light

12

 

13

Somewhat hard

14

 

15

Hard (heavy)

16

 

17

Very Hard

18

Extremely hard

19

 

20

Maximal

When rating your exertion you should think of how the entire body is feeling at that moment in time. Think of the strain and fatigue in both your muscles and your breathing. If your muscles are aching and feel very heavy, you are likely to be working at a hard intensity and should ease off slightly. If you find your breathing becomes uncomfortable, you are probably over exerting yourself and should slow down.

The ideal range to work at to encourage cardiovascular benefits during your conditioning phase is between the 'light' to 'somewhat hard' range. If you perceive your exertion as 'hard' or any further down the scale from this, you should reduce the intensity of the activity i.e. reduce your speed or resistance.

At a 'light' to 'somewhat hard' intensity you should feel warm, possibly slightly sweaty and your breathing should be deeper and faster. You should still be able to talk comfortably. If you are struggling to talk when walking, you are likely to be working too hard and should reduce the intensity.

How do i start to exercise?

As for any other type of exercise it is important to start with a small amount and build up gradually. Walking is an excellent way to start your exercise regime. You should begin every walk with a very gentle warm up. This can be incorporated into your walk as the first 10-15 minutes or can be conducted prior to setting out.

Start with a short walk, somewhere flat to begin, and walking at a steady pace. Progress by increasing the distance, then you can start to introduce a few hills into your route. When walking up inclines you will probably tire or become breathless faster so just reduce your walking speed to keep your RPE at light to somewhat hard. Remember that you should finish your walk with a cool down period of 10-15 minutes of low-intensity walking to help your heart rate return to a resting level.

It is normal to feel a little fatigued after exercise and a ‘tired’ day every now and again is normal. However If you notice you are feeling ‘very tired’ on alternate days you are probably increasing your activities at too fast a rate. Consider taking a few days rest, and start again being careful not to overdo it.

A walking programme guide

Stage of recovery (approximate) Length of walk (in minutes)
Only increase to next stage when ready
Stage 1

15 minute walk, gentle pace, daily

Stage 2

20 minute walk, moderate pace, daily

Stage 3

25 minute walk, moderate - brisk pace, daily

Stage 4

30 minute walk, brisk pace, daily

Stage 5

Add extra 5 minute walk for each stage increase

Target

30 minutes, brisk pace, daily

  • If you feel you are able to walk longer than 30 minutes then you can start at stage 4
  • Continue at any stage until you feel confident of progressing to the next. The time taken to progress varies between individuals
  • Reassess your progress at the end of each week. Think about:
    • Is it time for you to move on a stage?
    • Would you feel more comfortable at the same stage for a further week?

What is too much activity?

You are working too hard if:

  • You cannot ‘walk and talk’ for example if you cannot say your telephone number, including the area code, out loud and without gasping. If this happens slow down until you can say your telephone number without gasping
  • You become excessively tired either during or sometime after exercise or general activity
  • You are uncomfortably short of breath or perspiring profusely
  • You have chest pain or discomfort (angina)

Pacing yourself is the key to successful progress!


Other activities

You can apply this principle to other activities such as cycling, or swimming or gym exercises. You might even wish to progress to some sports if your symptoms allow. Thinking about your “rating your effort by how you feel” will guide you in what suits you. Contact sports such as rugby are not advised when taking anticoagulants due to the risk of bleeding.

When not to exercise

  • If you feel unwell, such as have a cold, flu or viral infection
  • Directly after a meal, wait two hours before you exercise
  • If you feel tired on a particular day take the day off from exercise or exercise less
  • In extremely hot weather you may tire more easily
  • If you have been diagnosed with heart failure, or have an Internal Cardio Defibrillator or a Cardiac Synchronisation Therapy device fitted you should consult your GP or local Cardiac Rehabilitation Service before embarking on an exercise regime

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