Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter

Abstract

Although the benefits of regular exercise in controlling cardiovascular risk factors have been extensively proven, little is known about the long-term cardiovascular effects of regular and extreme endurance sport practice, such as jogging, cycling, rowing, swimming, etc. Recent data from a small series suggest a relationship between regular, long-term endurance sport practice and atrial fibrillation (AF) and flutter. Reported case control studies included less than 300 athletes, with mean age between 40 and 50. Most series recruited only male patients, or more than 70% males, who had been involved in intense training for many years. Endurance sport practice increases between 2 and 10 times the probability of suffering AF, after adjusting for other risk factors. The possible mechanisms explaining the association remain speculative. Atrial ectopic beats, inflammatory changes, and atrial size have been suggested. Some of the published studies found that atrial size was larger in athletes than in controls, and this was a predictor for AF. It has also been shown that the left atrium may be enlarged in as many as 20% of competitive athletes. Other proposed mechanisms are increased vagal tone and bradycardia, affecting the atrial refractory period; however, this may facilitate rather than cause the arrhythmia. In summary, recent data suggest an association between endurance sport practice and atrial fibrillation and flutter. The underlying mechanism explaining this association is unclear, although structural atrial changes (dilatation and fibrosis) are probably present. Larger longitudinal studies and mechanistic studies are needed to further characterize the association to clarify whether a threshold limit for the intensity and duration of physical activity may prevent AF, without limiting the cardiovascular benefits of exercise.

Figure 1

Patients with a history of endurance sports before ablation (n = 31) developed significantly more atrial fibrillation than controls or those with a history of other type o sports activity after flutter ablation (reproduced from reference , with permission).

Figure 2

Thin-plate smoothing spline regression results assessing the non-linear relation between height and occurrence of lone atrial fibrillation (left panel), and the linear relation between left atrial (LA) diameter and occurrence of lone atrial fibrillation (right panel) (reproduced from reference , with permission).

Figure 3

Classical triangle of Coumel suggesting possible etiopathogenic factors influencing the development of atrial fibrillation in athletes.

Figure 4

Twenty-four hours recording of heart rate showing a nocturnal episode of atrial fibrillation.