Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature

Abstract

Although the benefits of exercise training have been shown repeatedly in many studies, its relationship with the occurrence of atrial fibrillation (AF) in competitive athletes still remains controversial. In the present review, we sought to demonstrate a comprehensive report of the incidence, pathophysiology, and therapeutic approaches to AF in elite athletes. A 2 to 10 times higher frequency of AF has been shown in many studies in high-intensity endurance athletes compared to individuals who do not exercise. Moreover, a U-shaped relationship between male elite athletes and AF is demonstrated through this finding, while the type and the years of physical activity seem to relate to AF development. A strong correlation seems to exist among the type of exercise (endurance sports), age (>55 years), gender (males), and the time of exercise training, all contributing to an increased risk of AF. The pathophysiology of AF still remains unclear; however, several theories suggest that complex mechanisms are involved, such as bi-atrial dilatation, pulmonary vein stretching, cardiac inflammation, fibrosis, and increased vagal tone. Elite athletes with AF require a comprehensive clinical evaluation and risk factor optimization, similar to the approach taken for nonathletes. Although anticoagulation and rate or rhythm control are cornerstones of AF management, there are still no specific guidelines for elite athletes.

Keywords: atrial fibrillation; elite athletes; management; pathophysiology.

Figure 1

Atrial fibrillation (AF) risk varies across the spectrum of exercise training. Approaching the extreme borders of physical activities (minimum physical activity at the one border and endurance sports at the other), there is an increase in AF incidence.

Figure 2

Presumed mechanisms of AF in elite athletes.

Figure 3

A proposed algorithm of clinical assessment and therapeutic strategy of an elite athlete with AF.