Download PDF
Int J Sports Med 2013; 34(05): 379-384
DOI: 10.1055/s-0032-1321896
Review
© Georg Thieme Verlag KG Stuttgart · New York

Atrial Fibrillation in Athletes

G. Mascia
1   Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
,
L. Perrotta
1   Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
,
G. Galanti
2   Sports Medicine Department, University of Florence, Florence, Italy
,
L. Padeletti
1   Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
› Author Affiliations
Further Information

Publication History



accepted after revision 28 June 2012

Publication Date:
05 October 2012 (online)

Also available at
    Permissions and Reprints

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.

Key words

arrhythmias - endurance sport - exercise performance
 

  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 5 Burstein B, Nattel S. Atrial fibrosis: mechanisms and clinical relevance in atrial fibrillation. J Am Coll Cardiol 2008; 51: 802-809
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 7 Chen PS, Tan AY. Autonomic nerve activity and atrial fibrillation. Heart Rhythm 2007; 4: S61-S64
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 10 Dernellis J, Panaretou M. Effect of C-reactive protein reduction on paroxysmal atrial fibrillation. Am Heart J 2005; 150: 1064
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 12 Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J 2005; 26: 2083-2092
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 30 Lampert R. Atrial fibrillation in athletes: toward more effective therapy and better understanding. J Cardiovasc Electrophysiol 2008; 19: 463-465
    CrossrefPubMedGoogle Scholar
  • 31 Lampert R. Evaluation and management of arrhythmia in the athletic patient. Prog Cardiovasc Dis 2012; 54: 423-431
    CrossrefPubMedGoogle Scholar
  • 32 Link MS, Estes NA. Athletes and arrhythmias. J Cardiovasc Electrophysiol 2010; 21: 1184-1189
    CrossrefPubMedGoogle Scholar
  • 33 Link MS, Homoud MK, Wang PJ, Estes NAM. Cardiac arrhythmias in the athletes. Cardiol Rev 2001; 9: 21-30
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 35 Lundström T, Karlsson O. Improved ventilatory response to exercise after cardioversion of chronic atrial fibrillation to sinus rhythm. Chest 1992; 102: 1017-1022
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 37 Maron BJ, Zipes DP. 36th Bethesda Conference: Eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005; 45: 1313-1375
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 39 Mont L. Arrhythmias and sport practice. Heart 2010; 96: 398-405
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 46 Pedersen BK, Febbraio MA. Muscle as an endocrine organ: focus on muscle-derived interleukin-6. Physiol Rev 2008; 88: 1379-1406
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 53 Samet P, Bernstein W, Levine S. Significance of the atrial contribution to ventricular filling. Am J Cardiol 1965; 15: 195-202
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 59 Trivax JE, McCullough PA. Phidippides cardiomyopathy: a review and case illustration. Clin Cardiol 2012; 35: 69-73
    CrossrefPubMedGoogle Scholar
  • 60 Turagam MK, Velagapudi P, Kocheril AG. Atrial fibrillation in athletes. Am J Cardiol 2012; 109: 296-302
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 66 Weight LM, Alexander D, Jacobs P. Strenuous exercise: analogous to the acute-phase response?. Clin Sci (Lond) 1991; 81: 677-683
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMed
  • 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
    CrossrefPubMedGoogle Scholar