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DOI: 10.1055/s-0032-1321896
Atrial Fibrillation in Athletes
Publication History
accepted after revision 28 June 2012
Publication Date:
05 October 2012 (online)
![](https://www.thieme-connect.de/media/sportsmed/201305/lookinside/thumbnails/10.1055-s-0032-1321896-1.jpg)
Abstract
Many studies have shown a relationship between long-term endurance sport practice and atrial fibrillation. Inflammation, anatomic remodelling, alterations in the autonomic system and neurohormonal activation are all possible explanations for the increased prevalence of this arrhythmia in athletes. Atrial fibrillation may determine disabling symptoms like palpitations and impaired physical performance, compromising eligibility for competitive activities, but exclusion from sport is not necessary for all athletes. Limited data are available on drug therapy and recently ablation resulted to be a particularly attractive option for young athletes with paroxysmal atrial fibrillation. The purpose of this review is to discuss mechanisms, clinical features, management of atrial fibrillation in competitive athletes, including criteria for eligibility and disqualification in sport practice.
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References
- 1 Atwood JE, Myers J, Sullivan M, Forbes S, Sandhu S, Callaham P, Froelicher V. The effect of cardioversion on maximal exercise capacity in patients with chronic atrial fibrillation. Am Heart J 1989; 118: 913-918
- 2 Baldesberger S, Bauersfeld U, Candinas R, Seifert B, Zuber M, Ritter M, Jenni R, Oechslin E, Luthi P, Scharf C, Marti B, Attenhofer Jost CH. Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists. Eur Heart J 2008; 29: 71-78
- 3 Benito B, Gay-Jordi G, Serrano-Mollar A, Guasch E, Shi Y, Tardif JC, Brugada J, Nattel S, Mont L. Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training. Circulation 2011; 123: 13-22
- 4 Brookes CI, White PA, Staples M, Oldershaw PJ, Redington AN, Collins PD, Noble MI. Myocardial contractility is not constant during spontaneous atrial fibrillation. Circulation 1998; 98: 1762
- 5 Burstein B, Nattel S. Atrial fibrosis: mechanisms and clinical relevance in atrial fibrillation. J Am Coll Cardiol 2008; 51: 802-809
- 6 Calvo N, Mont L, Tamborero D, Berruezo A, Viola G, Guasch E, Nadal M, Andreu D, Vidal B, Sitges M, Brugada J. Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. Europace 2010; 12: 30-36
- 7 Chen PS, Tan AY. Autonomic nerve activity and atrial fibrillation. Heart Rhythm 2007; 4: S61-S64
- 8 Chung MK, Martin DO, Sprecher D, Wazni O, Kanderian A, Carnes CA, Bauer JA, Tchou PJ, Niebauer MJ, Natale A, Van Wagoner DR. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation 2001; 104: 2886-2891
- 9 Daoud EG, Weiss R, Bahu M, Knight BP, Bogun F, Goyal R, Harvey M, Strickberger SA, Man KC, Morady F. Effect of an irregular ventricular rhythm on cardiac output. Am J Cardiol 1996; 78: 1433-1436
- 10 Dernellis J, Panaretou M. Effect of C-reactive protein reduction on paroxysmal atrial fibrillation. Am Heart J 2005; 150: 1064
- 11 Elosua R, Arquer A, Mont L, Sambola A, Molina L, García-Morán E, Brugada J, Marrugat J. Sport practice and the risk of lone atrial fibrillation: A case-control study. Int J Cardiol 2006; 108: 332-337
- 12 Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J 2005; 26: 2083-2092
- 13 Febbraio MA, Pedersen BK. Contraction-induced myokine production and release: is skeletal muscle an endocrine organ?. Exerc Sport Sci Rev 2005; 33: 114-119
- 14 Frustaci A, Chimenti C, Bellocci F, Morgante E, Russo MA, Maseri A. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997; 96: 1180-1184
- 15 Furlanello F, Bertoldi A, Dallago M, Galassi A, Fernando F, Biffi A, Mazzone P, Pappone C, Chierchia S. Atrial fibrillation in elite athletes. J Cardiovasc Electrophysiol 1998; 9: S63-S68
- 16 Furlanello F, Lupo P, Pittalis M, Foresti S, Vitali-Serdoz L, Francia P, De Ambroggi G, Ferrero P, Nardi S, Inama G, De Ambroggi L, Cappato R. Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition. J Cardiovasc Electrophysiol 2008; 19: 457-462
- 17 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol 2011; 57: 101-198
- 18 Gosselink AT, Bijlsma EB, Landsman ML, Crijns HJ, Lie KI. Long-term effect of cardioversion on peak oxygen consumption in chronic atrial fibrillation: a 2-year follow-up. Eur Heart J 1994; 15: 1368-1372
- 19 Gosselink AT, Blanksma PK, Crijns HJ, Van Gelder IC, de Kam PJ, Hillege HL, Niemeijer MG, Lie KI, Meijler FL. Left ventricular beat-to-beat performance in atrial fibrillation: contribution of Frank-Starling mechanism after short rather than long RR intervals. J Am Coll Cardiol 1995; 26: 1516-1521
- 20 Gosselink AT, Crijns HJ, Van Den Berg MP, van den Broek SA, Hillege H, Landsman ML, Lie KI. Functional capacity before and after cardioversion of atrial fibrillation: a controlled study. Br Heart J 1994; 72: 161-166
- 21 Grimsmo J, Grundvold I, Maehlum S, Arnesen H. High prevalence of atrial fibrillation in long-term endurance cross-country skiers: echocardiographic findings and possible predictors – a 28–30 years follow-up study. Eur J Cardiovasc Prev Rehabil 2010; 17: 100-105
- 22 Hagens VE, Ranchor AV, Van Sonderen E, Bosker HA, Kamp O, Tijssen JG, Kingma JH, Crijns HJ, Van Gelder IC. RACE Study Group . Effect of rate or rhythm control on quality of life in persistent AF. J Am Coll Cardiol 2004; 43: 241-247
- 23 Heidbuchel H, Anne W, Willems R, Adriaenssens B, Van de Werf F, Ector H. Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter. Int J Cardiol 2006; 107: 67-72
- 24 Hohnloser SH, Kuck K, Lilienthal J. Rhythm or rate control in AF – Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomized trial. Lancet 2000; 356: 1789-1794
- 25 Hornestam B, Hall C, Held P, Carlsson T, Falk L, Karlson BW, Lundström T, Peterson M. N-terminal proANF in acute atrial fibrillation: A biochemical marker of atrial pressures but not a predictor for conversion to sinus rhythm. Am Heart J 1998; 135: 1040
- 26 Jenkins LS, Brodsky M, Schron E, Chung M, Rocco Jr T, Lader E, Constantine M, Sheppard R, Holmes D, Mateski D, Floden L, Prasun M, Greene HL, Shemanski L. Quality of life in atrial fibrillation: the Atrial Fibrillation Follow-Up Investigator of Rhythm Management (AFFIRM) study. Am Heart J 2005; 149: 112-120
- 27 Kaarjalainen J, Kujala UM, Kaprio J, Sarna S, Viitasalo M. Lone atrial fibrillation in vigorously exercising middle aged men: case-control study. BMJ 1998; 316: 1784-1785
- 28 Kasapis C, Thompson PD. The effects of physical activity on serum C-reactive protein and inflammatory markers: a systematic review. J Am Coll Cardiol 2005; 45: 1563-1569
- 29 Lachance D, Plante E, Bouchard-Thomassin AA, Champetier S, Roussel E, Drolet MC, Arsenault M, Couet J. Moderate exercise training improves survival and ventricular remodeling in an animal model of left ventricular volume overload. Circ Heart Fail 2009; 2: 437-445
- 30 Lampert R. Atrial fibrillation in athletes: toward more effective therapy and better understanding. J Cardiovasc Electrophysiol 2008; 19: 463-465
- 31 Lampert R. Evaluation and management of arrhythmia in the athletic patient. Prog Cardiovasc Dis 2012; 54: 423-431
- 32 Link MS, Estes NA. Athletes and arrhythmias. J Cardiovasc Electrophysiol 2010; 21: 1184-1189
- 33 Link MS, Homoud MK, Wang PJ, Estes NAM. Cardiac arrhythmias in the athletes. Cardiol Rev 2001; 9: 21-30
- 34 Lipkin DP, Frenneaux M, Stewart R, Joshi J, Lowe T, McKenna WJ. Delayed improvement in exercise capacity after cardioversion of atrial fibrillation to sinus rhythm. Br Heart J 1988; 59: 572-577
- 35 Lundström T, Karlsson O. Improved ventilatory response to exercise after cardioversion of chronic atrial fibrillation to sinus rhythm. Chest 1992; 102: 1017-1022
- 36 Malouf JF, Kanagala R, Al Atawi FO, Rosales AG, Davison DE, Murali NS, Tsang TS, Chandrasekaran K, Ammash NM, Friedman PA, Somers VK. High-sensitivity C-reactive protein. A novel predictor for recurrence of atrial fibrillation after successful cardioversion. J Am Coll Cardiol 2005; 46: 1284-1287
- 37 Maron BJ, Zipes DP. 36th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005; 45: 1313-1375
- 38 Molina L, Mont L, Marrugat J, Berruezo A, Brugada J, Bruguera J, Rebato C, Elosua R. Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace 2008; 10: 618-623
- 39 Mont L. Arrhythmias and sport practice. Heart 2010; 96: 398-405
- 40 Mont L, Elosua R, Brugada J. Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter. Europace 2009; 11: 11-17
- 41 Mont L, Sambola A, Brugada J, Vacca M, Marrugat J, Elosua R, Paré C, Azqueta M, Sanz G. Long-lasting sport practice and lone atrial fibrillation. Eur Heart J 2002; 23: 477-482
- 42 Mont L, Tamborero D, Elosua R, Molina I, Coll-Vinent B, Sitges M, Vidal B, Scalise A, Tejeira A, Berruezo A, Brugada J. Physical activity, height, and left atrial size are independent risk factors for lone atrial fibrillation in middle-aged healthy individuals. Europace 2008; 10: 15-20
- 43 Morris JJ, Entman M, North WC, Kong Y, McIntosh H. The changes in cardiac output with reversion of atrial fibrillation in sinus rhythm. Circulation 1965; 31: 670-678
- 44 Naito M, David D, Michelson EL, Schaffenburg M, Dreifus LS. The hemodynamic consequences of cardiac arrhythmias: evaluation of the relative roles of abnormal atrioventricular sequencing, irregularity of ventricular rhythm and atrial fibrillation in a canine model. Am Heart J 1983; 106: 284-291
- 45 Pardaens K, Van Cleemput J, Vanhaecke J, Fagard RH. Atrial fibrillation is associated with a lower exercise capacity in male chronic heart failure patients. Heart 1997; 78: 564-568
- 46 Pedersen BK, Febbraio MA. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev 2008; 88: 1379-1406
- 47 Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG, Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, Di Luigi L. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007; 28: 2006-2010
- 48 Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, Borjesson M, Carrè F, Corrado D, Delise P, Dorwarth U, Hirth A, Heidbuchel H, Hoffmann E, Mellwig KP, Panhuyzen-Goedkoop N, Pisani A, Solberg EE, van-Buuren F, Vanhees L, Blomstrom-Lundqvist C, Deligiannis A, Dugmore D, Glikson M, Hoff PI, Hoffmann A, Hoffmann E, Horstkotte D, Nordrehaug JE, Oudhof J, McKenna WJ, Penco M, Priori S, Reybrouck T, Senden J, Spataro A, Thiene G. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005; 26: 1422-1445
- 49 Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations Revisited A Comparison of U.S. and European Criteria for Eligibility and Disqualification of Competitive Athletes With Cardiovascular Abnormalities. J Am Coll Cardiol 2008; 52: 1990-1996
- 50 Psychari SN, Apostolou TS, Sinos L, Hamodraka E, Liakos G, Kremastinos DT. Relation of elevated C-reactive protein and interleukin-6 levels to left atrial size and duration of episodes in patients with atrial fibrillation. Am J Cardiol 2005; 95: 764-767
- 51 Resnekov L, McDonald L. Electroversion of lone atrial fibrillation and flutter including haemodynamic studies at rest and on exercise. Br Heart J 1971; 33: 339-350
- 52 Roy D, Paillard F, Cassidy D, Bourassa MG, Gutkowska J, Genest J, Cantin M. Atrial natriuretic factor during atrial fibrillation and supraventricular tachycardia. J Am Coll Cardiol 1987; 9: 509
- 53 Samet P, Bernstein W, Levine S. Significance of the atrial contribution to ventricular filling. Am J Cardiol 1965; 15: 195-202
- 54 Shapiro W, Klein G. Alterations in cardiac function immediately following electrical conversion of atrial fibrillation to normal sinus rhythm. Circulation 1968; 38: 1074-1084
- 55 Sharifov OF, Fedorov VV, Beloshapko GG, Glukhov AV, Yushmanova AV, Rosenshtraukh LV. Roles of adrenergic and cholinergic stimulation in spontaneous atrial fibrillation in dogs. J Am Coll Cardiol 2004; 43: 483-490
- 56 Singh BN. Atrial fibrillation following investigation of rhythm management: AFFIRM trial outcomes. What might be their implications for arrhythmia control?. J Cardiovasc Pharmacol Therapeut 2002; 7: 131-133
- 57 Singh SN, Tang XC, Singh BN, Dorian P, Reda DJ, Harris CL, Fletcher RD, Sharma SC, Atwood JE, Jacobson AK, Lewis Jr HD, Lopez B, Raisch DW, Ezekowitz MD. Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: a Veterans Affairs Cooperative Studies Program Substudy. J Am Coll Cardiol 2006; 48: 721-730
- 58 Swanson DR. Atrial fibrillation in athletes: implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism. Med Hypotheses 2006; 66: 1085-1092
- 59 Trivax JE, McCullough PA. Phidippides cardiomyopathy: a review and case illustration. Clin Cardiol 2012; 35: 69-73
- 60 Turagam MK, Velagapudi P, Kocheril AG. Atrial fibrillation in athletes. Am J Cardiol 2012; 109: 296-302
- 61 Ueshima K, Myers J, Graettinger WF, Atwood JE, Morris CK, Kawaguchi T, Froelicher VF. Exercise and morphologic comparison of chronic atrial fibrillation and normal sinus rhythm. Am Heart J 1993; 126: 260-261
- 62 Ueshima K, Myers J, Morris CK, Atwood JE, Kawaguchi T, Froelicher VF. The effect of cardioversion on exercise capacity in patients with atrial fibrillation. Am Heart J 1993; 126: 1021-1024
- 63 Van Gelder IC, Crijns HJ, Blanksma PK, Landsman ML, Posma JL, Van Den Berg MP, Meijler FL, Lie KI. Time course of hemodynamic changes and improvement of exercise tolerance after cardioversion of chronic atrial fibrillation unassociated with cardiac valve disease. Am J Cardiol 1993; 72: 560-566
- 64 Vella L, Caldow MK, Larsen AE, Tassoni D, Della Gatta PA, Gran P, Russell AP, Cameron-Smith D. Resistance exercise increases NF-κB activity in human skeletal muscle. Am J Physiol 2012; 302: R667-R673
- 65 Watanabe T, Takeishi Y, Hirono O, Itoh M, Matsui M, Nakamura K, Tamada Y, Kubota I. C-reactive protein elevation predicts the occurrence of atrial structural remodeling in patients with paroxysmal atrial fibrillation. Heart Vessels 2005; 20: 45-49
- 66 Weight LM, Alexander D, Jacobs P. Strenuous exercise: analogous to the acute-phase response?. Clin Sci (Lond) 1991; 81: 677-683
- 67 Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD. Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with AF. N Eng J Med 2002; 347: 1825-1833
- 68 World Anti-Doping Agency Home page. Available at http://www.wada-ama.org/en/World-Anti-Doping-Program/Sports-and-Anti-Doping-Organizations/International-Standards/Prohibited-List/ Accessed March 27, 2012
- 69 Zehender M, Meinertz T, Keul J, Just H. ECG variants and cardiac arrhythmias in athletes: clinical relevance and prognostic importance. Am Heart J 1990; 119: 1378-1391