Atrial Fibrillation In Endurance Athletes Research Articles

A COMPLEX CASE OF EARLY ONSET ATRIAL FIBRILLATION IN AN ENDURANCE ATHLETE: THE IMPORTANCE OF FAMILY HISTORY

Abstract Introduction Early onset atrial fibrillation (AF) in an endurance athlete represents a challenge for the cardiologist, especially in apparent absence of an overt structural heart disease. Different genetic variants have been associated with early onset AF but indications to genetic testing are still under definition. Case A 54–year–old man (BMI 19 kg/sqm), previous competitive athlete (Nordic running and walking) presented to the Emergency Department with sudden onset palpitations and dyspnea due to high penetrance AF (145 bpm). Family history (FH) was positive for cerebrovascular accidents in both parents and for early onset (<60 years) AF in the father. The man had a recent history of borderline hypertension, of effort related syncope of and of infundibular, isolated, premature ventricular complexes during a maximal exercise stress test (otherwise negative for ischemia) which ultimately led to the denial of competitive sport eligibility. Sinus rhythm (SR) was acutely restored with flecainide and the patient was discharged with low dose nadolol. Cardiac US showed normal left ventricular (LV) dimensions and thicknesses (10 mm), with regular LVEF (60%) and global longitudinal strain (–18%), mildly dilated left atrium (LAVI 36 ml/sqm) and bi–leaflet mitral valve prolapse without significant mitral regurgitation, mitro–anular disjunction nor Pickelhaube sign; 24h Holter ECG showed SR with rare supraventricular (SV) ectopic beats and a 4 beats SV run. Due to the recurrence of short episodes of palpitations, rhythm control with flecainide and antithrombotic prophylaxis were started and AF ablation was planned. Genetic testing for early onset AF identified a nonsense variant (c.84665delG; p.Gly28222fs*2) in TTN gene, classified as likely pathogenic (C4), so far not reported in scientific literature. Also, despite a moderate–low cardiovascular risk as assessed by SCORE2, mostly due to the FH and the desire to engage in high intensity exercise, coronary CT was prescribed, which showed a critical coronary disease leading to stenting on left anterior descending artery and intermediate branch. Cardiac MRI was planned. Conclusions Early onset AF in endurance athletes should not be underrated and a thorough examination including a detailed family history should be performed. TTN is the single gene most frequently associated with early onset AF in absence of an overt structural heart disease, but the subsequent clinical evolution is still largely unknown.

Pace yourself: murine model insights into atrial fibrillation in endurance athletes.

Pace yourself: murine model insights into atrial fibrillation in endurance athletes.

Atrial fibrosis and local right atrial inflammation are characteristic of strenuous, but not moderate exercise, and underlie increased AF inducibility in heavily trained rats

Abstract Introduction The U-shaped relationship between exercise load and atrial fibrillation (AF) risk, where moderate exercise is protective but strenuous training increases the risk of AF, is currently well accepted (1, 2). Clinical and experimental data suggest that atrial fibrosis and parasympathetic tone (PT) enhancement may underlie the excess risk of AF in endurance athletes (3). Delving into the atrial differences between moderate exercise and strenuous training may be important to understand the pathophysiology of exercise-induced AF. Purpose To compare the atrial structural, electrophysiological and molecular remodelling occurring after long-term moderate and strenuous exercise. Methods Male Wistar rats were randomly assigned to sedentary (SED), moderate (MOD, 35 cm/s, 45 minutes) or high intensity exercise (INT, 60 cm/s, 60 minutes) for 16 weeks. An electrocardiogram (ECG) and electrophysiological study (EPS) were performed before sacrifice. Left (LA) and right (RA) atrial samples were collected for fibrosis assessment and a mRNA array. Results After the exercise protocol, weight of SED rats was higher (486±77 g) compared with both the MOD (377±28 g) and INT groups (385±43 g). In the ECG (Figure 1), INT rats presented a prolonged P-wave compared with SED and MOD. Both trained groups presented with significant bradycardia compared with SED, along with enhanced PT (heart rate variability: low to high frequency ratio). The remaining ECG parameters were similar between groups. Consistent with an enhanced PT, the Wenckebach cycle length was similarly prolonged in both trained groups in the EPS. Conversely, the sinus node recovery time was prolonged in INT rats compared with SED and MOD. AF inducibility increased from SED to MOD to INT. Myocardial fibrosis was measured in atrial samples stained with Sirius red. In both the RA and LA, fibrosis was significantly higher in the INT group (6,3±0.8 %) compared with the SED (4,4±0.2 %) and MOD (4,3±0.5 %) groups. An mRNA array showed large differences between atria. 384 and 419 genes were deregulated between INT and MOD (nominal p<0.05) in the RA and LA, respectively. Only 19 genes were consistent between both atria. In pathway analyses, the inflammatory response pathway was enriched (upregulation) in the RA, but not in the LA, of INT rats compared with MOD (Figure 2). Conclusions In healthy rats, strenuous training promoted a differential, pathological remodelling involving atrial fibrosis and sinus node dysfunction, compared with moderate exercise. Local inflammation may play a role in strenuous exercise-induced fibrosis in the RA. PT enhancement was similar in both groups.Figure 1.Figure 2.

Temporal relationship between training and episodes of atrial fibrillation in endurance athletes

Abstract Background Prolonged endurance training promotes exercise-induced cardiac remodeling and atrial fibrillation (AF), the most common arrhythmia among middle-aged endurance athletes. However, there is a lack of data on the impact of training sessions on the recurrence of AF episodes and current guidelines do not provide specific training recommendations for athletes diagnosed with AF. Both sympathetic stimulation during exercise and parasympathetic activity after exercise are possible mechanisms for recurrent episodes of AF. Purpose To assess the temporal relationship of training sessions with recurrent AF episodes among endurance athletes with paroxysmal AF. Methods The Effects of Detraining in Endurance Athletes with Atrial Fibrillation Trial is an international multicenter randomized controlled trial that includes athletes engaged in regular endurance sports ≥five hours per week, diagnosed with paroxysmal AF. AF episodes lasting ≥30 seconds were registered using wireless insertable cardiac monitors (ICM) and reviewed by an experienced cardiologist. Training sessions were registered using sports watches. We analyzed AF episodes and training data for the period from ICM implantation to randomization, and report event rates and rate ratios with 95% confidence intervals (CIs) for recurrent AF episodes during or within 3 hours after training sessions, compared to >3 hours after training. Results Eighteen athletes (1 female, 17 male) with a median age of 55 years (range 44-74) were included. The combined duration of monitoring was 845 days/20,280 hours (median 38.5, range 12-97 days). The athletes performed a total of 619 hours of training during 559 training sessions. In total, 66 AF episodes (median 1, range 0-15) were registered, of which 37 (56%) occurred within 24 hours after the start of a training sessions. Ten AF episodes (15%) occurred during a training session, 12 (18%) occurred within 3 hours after a training session and 44 (67%) occurred >3 hours after training. Figure 1 shows recurrent AF episodes during training (red bars) and within 24 hours from the start of a training session (blue bars) and smoothed density estimates. The event rate per 24 hours was 0.39 for AF during training, 0.17 the first 3 hours after training and 0.06 >3 hours after training. As compared to >3 hours after training, the rate ratio was 6.6 (95% CI 3.8 to 11.6) for recurrent AF episodes during training sessions and 3.9 (95% CI 2.2 to 6.9) for AF episodes during or within 3 hours after training. Conclusion Among middle-aged endurance athletes with paroxysmal AF, the rate of recurrent AF episodes was highest during and within 3 hours after training sessions. The impact of training and the pathophysiology of exercise-induced AF should be investigated further, with the aim of developing preventive strategies specific to athletic populations.Figure 1

The Experiences of Endurance Athletes With Atrial Fibrillation: Tensions and Takeaways.

Growing evidence indicates that chronic high-intensity endurance exercise predisposes male, middle-aged athletes to increased risk of atrial fibrillation (AF). The aetiology of AF in endurance athletes is multifactorial and remains incompletely understood. Despite their unique training demands, AF care in athletes remains largely based on evidence derived from the general population. Understanding the experiences of athletes with AF provides a necessary foundation for addressing challenges in managing their condition and identifying gaps in care. The purpose of this interpretive descriptive qualitative study was to describe the experiences and perspectives of endurance athletes living with AF. Masters athletes diagnosed with AF and aged between 35 and 60 years were recruited internationally through cardiology practices and social media. Ten middle-aged, male endurance athletes with AF and >1,500 lifetime training hours participated in individual, semi-structured interviews. Data were analysed using inductive thematic analysis. Three key themes were constructed: (1) tensions with training, (2) tensions with treatment plans, and (3) tensions with clinicians. Participants experienced a wide range of symptoms from AF that significantly affected their ability to train, and reacted negatively to medical treatment strategies that affected their exercise capacity and training performance. Athletes experienced tensions with providers who failed to acknowledge their athletic needs. Our results highlight the unique difficulties that male athletes with AF face in navigating between training and their disease, treatment, and clinicians. Shared decision-making between the athlete and provider is likely necessary for effective management of athletic AF.

The Complex but Fascinating Relationship between Sport and Atrial Fibrillation: From Pathophysiology to the Clinical Scenario

Atrial fibrillation (AF) is the most common cause of hospital admission among all arrhythmias in the general population. Moreover, AF represents the most common arrhythmia in the athletic population as well. The complex but fascinating relationship between sport and atrial fibrillation has not yet been fully clarified. Although the benefits of moderate physical activity in controlling cardiovascular risk factors and in reducing the risk of atrial fibrillation have been widely demonstrated, some concerns have been raised about the potential adverse effects of physical activity. Endurance activity in middle-aged men athletes appears to increase the risk of AF. Several different physiopathological mechanisms may explain the increased risk of AF in endurance athletes, including the imbalance of the autonomic nervous system, changes in left atrial size and function and presence of atrial fibrosis. The goal of this article is to review the epidemiology, pathophysiology and clinical management for AF in athletes, including pharmacological and electrophysiological strategies.

Occult atrial fibrillation in endurance athletes.

Occult atrial fibrillation in endurance athletes.

Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation.

Although the cardiovascular benefits of moderate exercise are well established, there is growing epidemiological support for the notion that high-intensity endurance athletics increases the risk of atrial fibrillation (AF). There are many gaps in evidence related to epidemiology and mechanisms of AF in endurance athletes. The proposed pathophysiological mechanisms include alterations of autonomic tone, electrical remodeling, anatomical remodeling, fibrosis, and inflammation. Clinical management of the athlete with AF often includes a period of decreased frequency, intensity, and duration of exercise with assessment for improvement in AF recurrence. Based on symptoms, a strategy of rate or rhythm control should be selected; however, due to side effects and intolerance of medications, ablation may be a preferred approach. The risks and benefits of anticoagulation for stroke prevention must be carefully assessed in the athlete with AF. All patients should be encouraged to be physically active with moderation; however, men should be advised of the higher risk of AF with long-term, high-intensity endurance training.

State of the Art Review: Atrial Fibrillation in Athletes.

Exercise has substantial health benefits with pleomorphic vascular, metabolic, psychological and anti-neoplastic actions resulting in improved quality of life and longevity. Despite these many benefits, numerous studies have shown that endurance athletes are more likely to develop atrial fibrillation (AF) than non-athletes. The type, intensity and amount of sport appears to influence the risk of developing AF. Several endurance sport activities have been shown to increase the risk of developing AF but an excess in AF has not been shown in non-endurance sports. Furthermore, lifetime hours of participation appear to increase the risk of developing AF. Intriguingly, women appear relatively protected and an association between endurance sport and AF has not been clearly demonstrated amongst female endurance athletes. The mechanisms by which endurance sport promotes the development of AF are unclear. There are, however, a number of pathophysiological mechanisms which are known to increase the risk of AF in non-athletes which have correlates in athletes. These include structural remodelling of the left atrium, elevated left atrial pressure, inflammation, myocardial fibrosis, vagal tone, sinus bradycardia and genetic predisposition. In this article, we explore how some of these mechanisms may contribute to the development of AF in endurance athletes.

Pathophysiology of atrial fibrillation in endurance athletes: an overview of recent findings.

Exercise training in general has been associated with a reduced risk of atrial fibrillation and associated morbidity among patients with this condition.[1][1]–[3][2] However, more strenuous endurance exercise (e.g., marathon running) appears to increase the risk of paroxysmal atrial fibrillation

Does endurance exercise cause atrial fibrillation in women?

Prolonged endurance sport practice might increase the risk of atrial fibrillation (AF), possibly caused by myocardial and autonomic adaption to exercise [ [1] Wilhelm M. Atrial fibrillation in endurance athletes. Eur. J. Prev. Cardiol. 2013; 21: 1040-1048 Crossref PubMed Scopus (57) Google Scholar ]. As recently addressed by Turagam et al., questions regarding the duration, intensity and type of exercise that increase the risk of AF, and the natural history of the arrhythmia in athletes, still remain unanswered [ [2] Turagam M.K. Velagapudi P. Alpert M.A. Does exercise cause atrial fibrillation?. Int. J. Cardiol. 2014; 181C: 245-246 PubMed Google Scholar ]. In addition, there is a lack of data on gender differences in the association between endurance exercise and AF.

Atrial fibrillation in endurance athletes

There is a growing population of veteran endurance athletes, regularly participating in training and competition. Although the graded benefit of exercise on cardiovascular health and mortality is well established, recent studies have raised concern that prolonged and strenuous endurance exercise may predispose to atrial and ventricular arrhythmias. Atrial fibrillation (AF) and atrial flutter are facilitated by atrial remodelling, atrial ectopy, and an imbalance of the autonomic nervous system. Endurance sports practice has an impact on all of these factors and may therefore act as a promoter of these arrhythmias. In an animal model, long-term intensive exercise training induced fibrosis in both atria and increased susceptibility to AF. While the prevalence of AF is low in young competitive athletes, it increases substantially in the aging athlete, which is possibly associated with an accumulation of lifetime training hours and participation in competitions. A recent meta-analysis revealed a 5-fold increased risk of AF in middle-aged endurance athletes with a striking male predominance. Beside physical activity, height and absolute left atrial size are independent risk factors for lone AF and the stature of men per se may explain part of their higher risk of AF. Furthermore, for a comparable amount of training volume and performance, male non-elite athletes exhibit a higher blood pressure at rest and peak exercise, a more concentric type of left ventricular remodelling, and an altered diastolic function, possibly contributing to a more pronounced atrial remodelling. The sports cardiologist should be aware of the distinctive features of AF in athletes. Therapeutic recommendations should be given in close cooperation with an electrophysiologist. Reduction of training volume is often not desired and drug therapy not well tolerated. An early ablation strategy may be appropriate for some athletes with an impaired physical performance, especially when continuation of competitive activity is intended. This review focuses on the prevalence, risk factors, and mechanisms of AF in endurance athletes, and possible therapeutic options.

Characterization of atrial fibrillation and the effect of pulmonary vein antrum isolation in endurance athletes

IntroductionEndurance sports have recently been recognized as a risk factor for atrial fibrillation (AF). This study aimed to characterize AF in endurance athletes and to examine the efficacy of pulmonary vein antrum isolation (PVAI) in an attempt to clarify the mechanism. Methods and resultsTwenty-two men (46±8 years old) with AF, who had no risk factors other than participation in long-term endurance sports, were examined; 12 patients had paroxysmal AF, 9 had persistent AF, and 1 had long-standing AF. Twelve patients (55%) were asymptomatic at rest. Nineteen patients (86%) experienced less exercise tolerance during AF than during sinus rhythm; exercise-induced paroxysmal AF was noted in 14 of these patients (64%). Antiarrhythmic drugs (AADs) were used in 18 patients, but were effective in only 3 patients (16%). Eleven patients underwent PVAI; in these patients, AF was eliminated without AADs in 9 patients (82%) and with AADs in 2 patients over an average follow-up period of 21±9 months. ConclusionAF in endurance athletes is frequently asymptomatic at rest, but manifests as reduced exercise tolerance. AF originates from the pulmonary veins; PVAI could be an effective non-pharmacologic therapy.

Characteristics and Efficacy of Pulmonary Vein Antrum Isolation in Endurance Athletes with Atrial Fibrillation

Long-term sports activities have recently been paid attention to be a risk factor of atrial fibrillation (AF). This study aimed to examine the mechanism of the AF and efficacy of pulmonary vein antrum isolation (PVAI) for the AF in endurance athletes. Pulmonary vein antrum isolation (PVAI) alone using EnSite system was performed in 10 athletes (46±7 years, 5 with persistent and 5 with paroxysmal, 39±4 mm mean left atrial diameter). All patients complained of impaired exercise tolerance. Only 3 patients suffered from palpitations and the other 7 patients felt no other symptoms during rest or mild exertion. Antiarrhythmic drugs were not effective in all patients. During a 17±9 month follow-up, 8 patients (80%) had no recurrence without antiarrhythmic drugs after a single PVAI session. Two patients had recurrences after the single session in whom one patient underwent repeat PVAIs twice because AF recurrence resulting from the LA-PV reconnections occurred. The remaining patient was rendered AF free with previously ineffective antiarrhythmic drug after a single PVAI. Finally, all patients felt improvement in exercise tolerance after a final PVAI. No procedure related complication was noted. In conclusion, our results suggest that AF is originated from the pulmonary veins and PVAI can be an effective therapy in athletic patients with AF like non-athletic patients.

Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes

AimsLong-term endurance sport practice has been increasingly recognized as a risk factor for lone atrial fibrillation (AF). However, data on the outcome of circumferential pulmonary vein ablation (CPVA) in endurance athletes are scarce. The aim of the study was to evaluate the efficacy of CPVA in AF secondary to endurance sport practice.Methods and resultsPatients submitted to CPVA answered a questionnaire about lifetime history of endurance sport practice. Endurance athletes were defined as those who engaged in >3 h per week of high-intensity exercise for at least the 10 years immediately preceding their AF diagnosis. A series of 182 consecutive patients was included (51 ± 11 years, 65% with paroxysmal AF, 81% men, 42 ± 6 mm mean left atrial diameter); 107 (59%) patients had lone AF, and 42 of them (23% of the study population) were classified as endurance athletes (lone AF sport group). Freedom from arrhythmia after a single CPVA was similar in the lone AF sport group compared with the remaining patients (P = 0.446). Left atrial size and long-standing AF were the only independent predictors for arrhythmia recurrence after ablation.ConclusionCircumferential pulmonary vein ablation was as effective in AF secondary to endurance sport practice as in other aetiologies of AF.