Pilates for atrial fibrillation (AFib): safe effort, heart rate and medicines, blood thinners, the evidence, and a class

No study has tested Pilates in AF

We found no Pilates study of any kind in people with AF, and none is registered. So this page is about doing Pilates safely with AF, not about Pilates treating it.

Source 1

Pilates never replaces your AF treatment

There's no cure, the NHS says, but treatment helps manage symptoms and lowers the risk of clots, stroke and heart failure. AF makes a stroke about five times more likely, and anticoagulants (blood thinners) are the most effective way to cut that risk.

Sources 2, 3, 4

Exercise in general is recommended for AF

In a Cochrane review of 20 trials, exercise-based rehabilitation probably made AF less likely to come back and eased symptoms, and in one trial, 40% of people were free of AF a year after a 6-month programme, against 20%. The European guideline recommends a tailored exercise programme for AF. That evidence is mostly for aerobic exercise, sometimes with strength work.

Sources 5, 6, 4

Where Pilates fits

The American College of Sports Medicine (ACSM) puts aerobic activity and strength training at the heart of an AF programme, and lists yoga, tai chi and Pilates as other options for balance, flexibility and strength. Walking or cycling supplies the aerobic part, building to 150 minutes a week; Pilates adds strength, mobility and balance.

Sources 7, 2, 8

Judge effort by how you feel, not your pulse

With an irregular pulse, heart rate can't measure effort, and watches read it too low during AF. Work at a pace where you can still talk, and keep breathing: no breath holds.

Sources 8, 9, 10

On a blood thinner, Pilates is fine: plan for knocks and falls

An expert review lists Pilates among the activities generally permitted on a blood thinner. Falls aren't a reason to stop it, NICE (the National Institute for Health and Care Excellence) says, but people with AF fall a little more often, so do balance work with a hand on the wall, pad the floor, and get any head injury checked.

Sources 11, 12, 13, 14

What AF isStrong evidence

"Atrial fibrillation (sometimes called afib or AF) is a type of heart rhythm problem where your heartbeat is not steady", the NHS says. It can come and go, stop with treatment, or stay. Symptoms include an irregular pulse, palpitations, tiredness, "finding it harder to exercise", chest pain and feeling breathless, light-headed or faint, though "Sometimes there are no symptoms": about a third of people with AF have none.

Sources 2, 15

Who gets itStrong evidence

"Age is the most important risk factor for AF", and the lifetime risk is "as high as 1 in 3 for older individuals". The NHS lists being 55 or older, being a man, being overweight, smoking, some medicines and endurance sports such as long-distance running, cycling or skiing.

Sources 15, 4, 2

Treatment comes firstStrong evidence

The European guideline says "the risk of ischaemic stroke in AF is increased five-fold, and one in every five strokes is associated with AF" (an ischaemic stroke is one caused by a clot). Treatment includes medicines to control the rate or rhythm, anticoagulants, cardioversion and ablation, and the British Heart Foundation (BHF) says "Anticoagulant drugs and DOACs are the most effective treatments to reduce the risk of stroke in people with atrial fibrillation" (DOACs are the newer direct oral anticoagulants).

Sources 4, 2, 3

Why exercise feels different with AFStrong evidence

Your heart rate can rise and fall more quickly than normal, which the BHF says "can cause shortness of breath, chest pain or dizziness, so it's important to warm up before and cool down afterwards". Rate-control tablets blunt the rise in heart rate, and beta blockers can make exercise feel harder.

Sources 8, 16, 17

How hard Pilates is

Most Pilates is light to moderate work; our Pilates for heart health guide gives the figures. The NHS counts Pilates as muscle strengthening, "not always an aerobic activity, so you'll need to do them in addition to your 150 minutes of aerobic activity". The parts of a class that matter with AF are the warm-up, holds and breath holding, legs-overhead and head-down moves, quick changes from lying to standing, hot rooms, and balance work on a blood thinner (below).

Source 18

No Pilates study in AFStrong evidence

Searches of PubMed, Europe PMC (in English, Portuguese and Spanish) and ClinicalTrials.gov found no Pilates study of any kind in AF, and none registered. Pilates has been tested in heart disease only in two tiny Brazilian studies (16 people with heart failure, and 40 after bypass surgery), and neither mentions AF.

Sources 1, 19, 20

Exercise-based rehabilitationStrong evidence

In a 2024 Cochrane review (20 trials, 2,039 people), exercise-based rehabilitation probably reduced AF coming back (risk ratio 0.70, moderate certainty) and eased symptoms. Effects on deaths and serious harms were too uncertain to call: "There is not enough evidence to know the effect of exercise on death or serious unwanted effects." Aerobic exercise alone and aerobic plus strength work had similar effects.

Source 5

The ACTIVE-AF trialEmerging evidence

In 120 people, 6 months of supervised and home aerobic exercise: "By 12 months, freedom from AF was achieved in 24 (40%) of 60 patients in the exercise group and 12 (20%) of 60 patients in the control group".

Source 6

Harder isn't betterEmerging evidence

In 76 people, "High intensity physical exercise was not superior to low intensity physical exercise in reducing burden of atrial fibrillation" over 12 weeks. In 51 people, interval training cut the time spent in AF from 8.1% to 4.8%, while it rose from 10.4% to 14.6% without training.

Sources 21, 22

Strength workEmerging evidence

No trial has tested strength training alone in AF. Programmes that combined it with aerobic work improved strength and exercise capacity without more AF coming back: after ablation, 6 months of moderate endurance and resistance training raised grip and leg strength (AF returned in 21.4% against 25.8%). The gains fade when you stop: in older adults with permanent AF, improvements in fitness and muscle function "were lost" after 3 months off.

Sources 23, 24, 25, 26

The guidelinesStrong evidence

The European Society of Cardiology (2024): "A tailored exercise programme is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence." The American guideline (2023) recommends moderate to vigorous exercise training "to a target of 210 minutes per week", and the Asia Pacific guideline (2026) says "Aerobic exercise, up to 210 min per week, should be recommended". None mentions Pilates.

Sources 4, 27, 28

Where Pilates fitsEmerging evidence

The ACSM's AF handout says aerobic activity and strength training "are at the heart of a program for those with atrial fibrillation", and that yoga, tai chi and Pilates "All promote balance, flexibility and strength". The AF Association says once AF has been assessed and treated, doctors "generally encourage patients to return to full and normal activities". This is expert advice, not trial evidence; we read it as Pilates being the strength, mobility and balance part of an AF week, at a light to moderate effort, alongside the aerobic exercise.

Sources 7, 29, 11

Yoga and other mind-body studiesMixed evidence

One uncontrolled yoga study counted fewer symptomatic episodes (3.8 to 2.1). Two Swedish randomised trials (80 and 132 people) measured quality of life and blood pressure, not episodes, and in the larger "After 12 weeks, there were no differences in health-related quality of life between the groups". The first randomised trial to measure episodes says "However, randomized data are absent" and hasn't reported. A widely shared 538-person yoga study is a conference abstract that was never published in full. Our yoga for atrial fibrillation guide covers these.

Sources 30, 31, 32, 33, 34

Go by how you feelStrong evidence

Because your pulse is irregular, checking your heart rate won't accurately measure a workout's intensity, so think about how you're feeling, the BHF says. European sports cardiology guidance agrees: in AF, judge effort by how hard it feels, or by power on a bike.

Sources 8, 35

The talk test and the Borg scaleEmerging evidence

The talk test is valid "to monitor exercise training for patients with atrial fibrillation": you should be able to talk, but not sing. The trial that compared intensities set them by the Borg scale of how hard exercise feels (11 to 13 for low intensity), because heart rate "could be inaccurate" in AF or on rate-control medicines. Our heart rate zones calculator explains the Borg scale.

Sources 10, 21

Watches and heart rate monitorsEmerging evidence

In a study of 102 people in hospital, measured at rest, smartwatches matched an electrocardiogram (ECG) well in a normal rhythm but read heart rate too low during AF: by 8 beats on average for one watch and 28 for another, with wide variation. Don't rely on a watch's heart rate to judge your effort while you're in AF.

Another small study of a smartwatch in 50 people with AF also urged caution.

Sources 9, 36

Warm up and cool down gradually

Start exercise gradually and decrease the intensity gradually, so your breathing returns to normal before you stop. With a heart condition, the BHF suggests a warm-up of at least 15 minutes and a cool-down of at least 10.

Sources 8, 37

Not during an episodeStrong evidence

The NHS says you should be able to carry on doing most things as usual, including exercise, "But avoid intense exercise and try not to exercise when you're having symptoms of atrial fibrillation." If you're in AF all the time, the BHF says you can exercise "as long as your heart rate is under control, you are stable on your treatment and you are feeling well".

Sources 2, 8, 35

If AF starts during Pilates

Slow down and stop, then sit and rest. Call 999 for chest pain, fainting, severe breathlessness or the other signs in the warning signs below. If it settles and you feel well, don't exercise again that day, and tell your doctor or AF nurse (our suggestion, in line with the NHS advice not to exercise when you have symptoms).

Sources 2, 8, 35

Beta blockers

Beta blockers slow your heartbeat and may make you feel more tired or less energetic. Use the talk test or the Borg scale rather than heart rate. If a beta blocker makes you dizzy, the NHS says not to drive, ride a bike or use machinery until the dizziness stops. Talk to your doctor if you want to change your exercise routine, and don't change your dose yourself.

Sources 17, 37, 8

What one trial foundEmerging evidence

In 60 people with permanent AF, "The exercise capacity (peak VO2) was significantly lower during treatment with metoprolol and carvedilol compared with baseline (no treatment) or treatment with diltiazem and verapamil". Metoprolol and carvedilol are beta blockers; peak VO2 is the most oxygen your body can use. If your tablets leave you tired, tell your team rather than changing the dose.

Sources 16, 4

Getting up from the floor

If you feel light-headed when you stand, come up in stages: roll to your side, sit for a few breaths, then stand with a chair or wall within reach (our suggestion).

Pilates isn't a contact sportEmerging evidence

An expert review of anticoagulants in athletes puts "Yoga, Pilates" with walking and swimming: "Generally permitted. Minimal trauma risk; appropriate protective equipment advised." European sports guidance advises against "Sports with direct bodily contact or prone to trauma" on anticoagulants. In a Pilates class, the risks are falls from balance work, knocks from equipment and bruising from rolling or kneeling on a hard floor. This rests on a narrative review and reasoning, not trials.

Sources 11, 35, 38

Avoid contact sport

If you take anticoagulants, you're more likely to bleed and bruise badly if you have an accident, so the BHF says avoid contact sports. The NHS says your GP or anticoagulant clinic may advise this, and to use protection when playing sports. European sports cardiology guidance agrees.

Sources 8, 38, 35

Falls aren't a reason to stop your blood thinnerStrong evidence

NICE: "Do not withhold anticoagulation solely because of a person's age or their risk of falls." It explains that "falls are rarely a cause of major haemorrhage", and the Asia Pacific guideline agrees. A decision analysis found "patients' propensity to fall is not an important factor in this decision"; in 515 people on anticoagulants, "only 3 major bleeds occurred directly after a fall" in a year; and in a Swiss cohort of 2,154 people with AF, "We found no association between recurrent falls and risk of major bleeding". Never stop a blood thinner yourself.

Sources 12, 28, 39, 40, 13

But plan for fallsEmerging evidence

People with AF fall a little more often than people without (odds ratio 1.19) and faint more often (1.88). In trials, people who had fallen before did worse overall, though the newer anticoagulants did better than warfarin in them. The answer is falls prevention: strength and balance work, with a hand on the wall. Our Pilates for balance guide shows how.

Sources 14, 41, 42

In class (our suggestions)

Pad the floor and your knees, leave out rolling moves on a hard floor, keep a hand on the wall or a chair for balance work, keep your fingers clear of reformer springs and the carriage, and tell the teacher you take a blood thinner. These are our suggestions, from the NHS advice to "avoid minor injuries" and the apixaban page's note that you may get "bruises that come up more easily and take longer to fade than usual"; no study has tested them.

Sources 38, 43

Head injuries

Get help from NHS 111 if you've had a head injury and take medicine that thins your blood. Seek immediate medical attention after a major accident, a significant blow to the head, or bleeding you can't stop. If you're told to go to A&E (accident and emergency), don't drive yourself there.

• Call 999 if someone has hit their head and has been knocked out and not woken up, can't stay awake or keep their eyes open, or has a fit.
• Call 999 if they have new numbness or weakness, or problems with their vision or hearing, or with walking, balance, understanding, speaking or writing.
• Call 999 if they fell from more than 1 metre or 5 stairs, or hit their head at high speed.

Sources 44, 43, 45

Why head injuries get checkedEmerging evidence

After a minor head injury on a newer anticoagulant, a serious brain injury was found in 3.4% of people (5 of 148). NICE's head injury guideline says to consider a brain scan for people on anticoagulants after a head injury, even with no other reason for one.

Sources 46, 47

Keep breathing: no breath holdsMixed evidence

No study has tested breath holding or straining during exercise in AF. Indirectly, breathing in hard against a closed airway brought on extra heartbeats in the upper chambers in 55% of 44 people with AF that comes and goes, and very long breath holds (about 4 to 5 minutes) brought on extra beats in 12 of 16 healthy divers. The ACSM's AF handout says: "Avoid straining or holding your breath when lifting." So breathe out on the effort and leave out box and 4-7-8 breathing holds: a sensible precaution, not a proven rule.

Sources 1, 48, 49, 7

Keep holds short

Come out of any position after a few breaths (our suggestion). If you also have heart failure, leave planks out, as the plank move pages say.

Legs over your head

Leave out the roll-over, jack knife, control balance and boomerang, which take your legs over your head. No trial has tested them in heart disease: this is a precaution, as our yoga for heart health guide leaves out the plough and shoulder stand.

Changing position

Do standing work first and mat work later, as our heart health class does, and come up from the floor in stages (our suggestion).

Hot rooms

No trial has tested hot Pilates in AF. The NHS lists dehydration among AF triggers, alongside caffeine, stress and lack of sleep, so choose a class at room temperature and drink water (our suggestion).

Source 2

Triggers people reportEmerging evidence

People with AF that comes and goes most often report alcohol (35%), caffeine (28%), exercise (23%) and lack of sleep (21%) as triggers. That's what people report, not proof of cause; if exercise seems to set yours off, tell your team.

Source 50

On a blood thinner

Pad the floor and your knees, leave out rolling like a ball, the seal and the open leg rocker unless you're on a thick mat, keep a hand on the wall or a chair for balance work, and take care with reformer springs and the foot bar (our suggestions).

Leave out the legs-overhead moves

The roll-over, jack knife, control balance, boomerang, high scissors and high bicycle: leave them out (a precaution, not a trial finding).

Light-headed on rate-control tablets

Stand up in stages after mat work, and use a chair class on days you feel unsteady.

Heart failure as well

Leave out planks and long holds, and skip the class on a day you feel more tired or breathless than normal; our Pilates for heart health guide covers heart failure.

After ablation or cardioversion

Follow your hospital's advice on when to restart; our exercise with AF guide gives typical timings.

A pacemaker or implanted defibrillator (ICD)

Our Pilates for heart health guide and exercise with a pacemaker or ICD guide cover the arm limits after the device is fitted.

Osteoporosis

Use head-down versions of curl-ups and bend from your hips, as our Pilates for osteoporosis guide explains.

Call 999 now

Call 999 if:

• You have chest pain that feels tight or like squeezing on your chest.
• You have chest pain that spreads to your arms, neck or jaw.
• You're having severe difficulty breathing: you're gasping, choking or not able to get words out.
• Your lips or skin are pale, blue or grey. On brown or black skin, this may be easier to see on the palms of the hands.
• Someone has passed out and is not responding normally.

Source 51

While you wait for help

Don't drive yourself to A&E. Sit and rest on the floor with your knees bent and your back supported. Take a 300 mg aspirin if you have one and aren't allergic to aspirin, and use your GTN if you have angina. If someone stops responding and stops breathing, start CPR (cardiopulmonary resuscitation).

Source 51

A fast or irregular heartbeat

Call 999 or go to A&E if palpitations don't go away, or come with chest pain, shortness of breath, feeling faint or fainting. With a fast or irregular heartbeat, the NHS also lists sweating, feeling or being sick, dizziness, a severe headache, weakness or numbness on one side, blurred vision, and confusion or difficulty speaking as reasons to call 999. If palpitations have stopped, ask for an urgent GP appointment or call NHS 111.

Sources 52, 2

Signs of a stroke: call 999

Call 999 (911 in the US) if you think you're having, or have had, a stroke, or you've had signs of a stroke in the last 24 hours, even if they've stopped. The NHS uses FAST:

• Face: one side of your face may droop, and it might be hard to smile.
• Arms: you may not be able to lift both arms and keep them there, because of weakness or numbness in one arm.
• Speech: you may slur your words or sound confused.
• Time: call 999.

Source 53

Other signs of a stroke

Other signs include weakness or numbness down one side, blurred vision or loss of sight, difficulty speaking or finding words, confusion and memory loss, feeling dizzy or falling over, a severe headache, and feeling or being sick. Don't drive yourself to A&E.

Source 53

Fainting

Call 999 if someone has fainted while exercising, or while lying down. After any other faint, see a GP.

Source 54

Call NHS 111 or ask for an urgent GP appointment

If:

• You're suddenly more short of breath than usual.
• You have chest pain and feel sick or are being sick.
• You have chest pain and your heart feels like it's racing, going too slowly, skipping a beat or fluttering.

Source 51

See a GP

If:

• You think you may have symptoms of AF.
• You have heart palpitations that keep happening or are getting worse.
• You've been diagnosed with AF and treatment isn't helping your symptoms.

Source 2

On a blood thinner: signs of bleeding

Severe or repeated bleeding needs medical attention straight away: call 111 or go to A&E. The NHS lists these signs of too much bleeding:

• Blood in your pee or poo, or black poo.
• Severe bruising.
• Nosebleeds lasting longer than 10 minutes.
• Vomiting or coughing up blood.
• Sudden severe back pain.
• Difficulty breathing or chest pain.

Source 45

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 55

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

Source 55

"You shouldn't exercise with AF"Strong evidence

Exercise-based rehabilitation probably made AF less likely to come back, every major guideline recommends exercise, and the BHF says it's "unlikely that exercise will make your AF worse". The cautions are about exercising during symptoms and very hard endurance training.

Sources 5, 4, 27, 28, 8

"Exercise causes AF"Mixed evidence

Regular activity at guideline levels is linked with a slightly lower risk of AF. Very high volumes of endurance sport over many years go with more AF; Pilates is light to moderate work, nothing like that.

Sources 56, 57, 4

"Your heart rate or watch tells you how hard you're working"Strong evidence

In AF, European guidance says effort can only be judged by how hard it feels or by power on a bike, and watches read heart rate too low during AF. Use the talk test.

Sources 35, 9, 10

"Pilates, yoga or a breathing trick can cure or stop AF"Strong evidence

No Pilates study exists, no randomised yoga trial has reported on episodes yet, and no technique has been shown to stop an episode.

Sources 1, 32, 33, 58

"On a blood thinner you can't do Pilates or floor work"Emerging evidence

Only contact or trauma-prone sport is advised against, and an expert review lists Pilates as generally permitted. Pad the floor, use a hand on the wall for balance, and get any head injury checked.

Sources 35, 38, 11

"If you might fall, you should come off your blood thinner"Strong evidence

NICE says don't withhold anticoagulation solely because of age or falls risk, and recurrent fallers had no more major bleeding in a Swiss cohort. The answer is falls prevention: strength and balance work.

Sources 12, 28, 13

"Strength work is dangerous with AF"Emerging evidence

No trial has tested strength training alone, but programmes that combined it with aerobic exercise were safe and improved strength without more AF coming back. The ACSM's AF handout recommends strength training, without straining or holding your breath.

Sources 23, 24, 7

"Holding your core means holding your breath"Emerging evidence

Pilates breathing is continuous. Breathe out on the effort and never hold your breath.

Source 7

"A 538-person study proved yoga halves AF episodes"Strong evidence

It's a 2020 conference abstract that was never published in full, and it contradicts itself.

Source 34