Ablation of Atrial Fibrillation in Athletes: CON
Editor's Note: This is the Con article of a two-part Pro/Con Expert Analysis. Click here for the Pro article.
Atrial Fibrillation (AF) is the most common arrhythmia in the general population and in athletes, particularly in middle aged athletes participating in endurance sports.10 However, it has also been noted to occur in young athletes without traditional risk factors. The prevalence in athletes has been reported as occurring anywhere from 0.2% to 63%.3,4,7 AF is an important topic in sports and exercise cardiology due to its prevalence and the development of resting and exertional symptoms.
The pathophysiology of AF in athletes is complex and is believed to be multifactorial, with contributions from genetic predisposition, atrial ectopy, and sports supplements, combined with cardiac remodeling, fibrosis, inflammation, and fibrosis associated with exercise.10,2 Other changes associated with training including electrolyte abnormalities, autonomic changes, and even gastroesophageal reflux disease are also believed to contribute to the development of AF in this population.10
For the purposes of this Expert Analysis, we are presuming the athletes in question are mostly those with paroxysmal AF and "structurally normal" hearts. The initial approach to both athletes and non-athletes with AF should include stroke risk assessment and rhythm control depending on symptoms.14 Indeed, catheter ablation may be a reasonable initial approach in athletes with recurrent and symptomatic paroxysmal AF.14,15,16,17 Certainly, a thorough discussion about the risks and benefits of pharmacologic versus ablative therapy must be had. The potential for femoral vein complications, for example, could be a particular concern for the active athlete. For the patient not requiring chronic anticoagulation and/or determined to have a low CHA2DS2VASC score, oral anticoagulation is normally required after ablation, for at least 6 weeks post procedure and would increase the risk of major bleeding in contact sports such as football and would require temporary withdrawal from sport.
For all athletes diagnosed with AF, one initial approach could be to decrease training for a period of time as overtraining in athletes can be responsible for AF.2,12,11,10 The Study Group on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation recommends that athletes in an early stage of paroxysmal AF should discontinue training for 2 months to stabilize sinus rhythm.5 Further treatment options can then be formulated in response to the degree of improvement that is experienced by the athlete. We recognize that many athletes will be resistant to detraining and this may not be a realistic option.
If an athlete has paroxysmal AF and remains asymptomatic, then he or she may not need to pursue a rate or rhythm control strategy and can continue participation in sports. This would be an attractive option especially for those with low risk for stroke (CHA2DS2VASC of 1 or less). The need for anticoagulation should be assessed on a case by case basis. Aside from the rate or rhythm control question, the other tenant of management of AF in athletes involves potential anticoagulation to reduce stroke risk. Risk stratification is done with CHA2DS2-Vasc score, just like in the general population. In those with low risk (score of 0-1), no antithrombotic medication is recommended.10 Athletes with a higher risk of stroke warrant anticoagulation with either warfarin or one of the novel anticoagulants. Athletes who are anticoagulated should be excluded from participation in contact sports where there is a risk of trauma.5 Of note, the role of aspirin for primary prevention of stroke in AF patients has come into question in recent years.18,19
For those who do not tolerate the arrhythmia well, rate control or rhythm control is warranted. Rate control is challenging as beta blockers are prohibited by the World Anti-doping Agency10 and may not be an option for those participating in competitive sports unless they are able to obtain a therapeutic use exemption from governing anti-doping agencies.10,9 Blunting of the maximum heart rate with beta blockers can lead to decreased performance. Furthermore, rhythm control should be considered in the patient with frequent paroxysms of AF as progression to persistent AF portends a worse cardiovascular prognosis.20 For these reasons, the provider should not necessarily settle for rate control.
Class I antiarrhythmic drugs can be taken regularly or as a "pill in pocket" to treat paroxysmal AF in athletes.2 Flecainide is a popular choice for vagally-mediated paroxysmal AF in athletes without structural heart disease.1 However, caution must be exercised as there is pro-arrhythmic risk with flecainide use in competitive sports due to adrenergic hypertonia.12 Although Class I medications can reduce the recurrence of AF episodes, AF can be converted to atrial flutter and so AV nodal blockers (calcium channel or beta blockers) are often prescribed in conjunction with the flecainide but this may not be readily accepted by the athlete.6,8 Before prescribing flecainide, significant CAD and structural heart disease should be ruled out.
There is growing evidence for the role of exercise training and physical activity in reducing AF burden, even in those referred for AF ablation.21,22,23,24 Interestingly, intense endurance athletes have significant increased risk of AF, up to several fold.25,26 Thus, there appear to be U shaped dose response to exercise. But in spite of the potential increased AF risk with too much exercise, the evolving exercise story underscores the importance of risk factor modification in AF patients. Hence, it would be reasonable to begin managing AF by evaluating for and treating risk factors. In 2015, the American Heart Association and the American College of Cardiology released the following recommendations regarding athletes with AF:13
- Athletes with AF should undergo a workup that includes thyroid function, tests, queries for drug use, ECG, and echocardiogram (Class I; Level of Evidence B).
- Athletes with low-risk AF that is well tolerated and self-terminating may participate in all competitive sports without therapy (Class I; Level of Evidence C).
- In athletes with AF, when antithrombotic therapy, other than aspirin, is indicated, it is reasonable to consider the bleeding risk in the context of the specific sport before clearance (Class IIa; Level of Evidence C).
- Catheter ablation for AF could obviate the need for rate control or antiarrhythmic drugs and should be considered (Class IIa; Level of Evidence B).
- Bove A. Arrhythmias in professional athletes: focus on atrial fibrillation. ACC Curr Journal Rev 2004;13:47-8.
- Calvo N, Brugada J, Sitges M, Mont L. Atrial fibrillation and atrial flutter in athletes. Br J Sports Med 2012;46:i37-43.
- Coelho A, Palileo E, Ashley W, et al. Tachyarrhythmias in young athletes. J Am Coll Cardiol 1986;7:237-43.
- Furlanello F, Bertoldi A, Dallago M, et al. Atrial fibrillation in elite athletes. J Cardiovasc Electrophysiol 1998;9:S63-8.
- Heidbuchel H, Panhuyzen-Goedkoop N, Corrado D, et al. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions part I: supraventricular arrhythmias and pacemakers. Eur J Cardiovasc Prev Rehabil 2006;13:475-84.
- Nabar A, Rodriguez LM, Timmermans C, van den Dool A, Smeets JL, Wellens HJ. Effect of right atrial isthmus ablation on the occurrence of atrial fibrillation: observations in four patient groups having type I atrial flutter with or without associated atrial fibrillation. Circulation 1999;99:1441-5.
- Pelliccia A, Maron BJ, Di Paolo FM, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 2005;46:690-6.
- Reithmann C, Dorwath U, Dugas M, et al. Risk factors for recurrence of atrial fibrillation in patients undergoing hybrid therapy for antiarrhythmic drug-induced atrial flutter. Eur Heart J 2003;24:1264-72.
- Sorokin AV, Araujo CG, Zweibel S, Thompson PD. Atrial fibrillation in endurance-trained athletes. Br J Sports Med 2011;45:185-8.
- Turagam MK, Flaker GC, Velagapudi P, Vadali S, Alpert MA. Atrial fibrillation in athletes: pathophysiology, clinical presentation, evaluation and management. J Atr Fibrillation 2015;8:1309.
- Turagam MK, Velagapudi P, Kocheril AG. Atrial fibrillation in athletes: the role of exercise. J Atr Fibrillation 2104;6:1004.
- Turagam MK, Velagapudi P, Kocheril AG. Atrial fibrillation in athletes. Am J Cardiol 2012;109:296-302.
- Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NA. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: task force 9: arrhythmias and conduction defects: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2412-23.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130:2071-104.
- Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation: a randomized trial. JAMA 2005;293:2634-40.
- Morillo CA, Verma A, Connolly SJ, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. JAMA 2014;311:692-700.
- Cosedis Nielsen J, Johannessen A, Raatikainen P, et al. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med 2012;367:1587-95.
- Aguilar M, Hart R. Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev 2005:CD001925.
- Sjalander S, Sjalander A, Svensson PJ, Friberg L. Atrial fibrillation patients do not benefit from acetylsalicylic acid. Europace 2014;16:631-8.
- de Vos CB, Pisters R, Nieuwlaat R, et al. Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis. J Am Coll Cardiol 2010;55:725-31.
- Pathak RK, Middeldorp ME, Lau DH, et al. Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: the ARREST-AF cohort study. J Am Coll Cardiol 2014;64:2222-31.
- Elliott AD, Mahajan R, Pathak RK, Lau DH, Sanders P. Exercise training and atrial fibrillation: further evidence for the importance of lifestyle change. Circulation 2016;133:457-9.
- Malmo V, Nes BM, Amundsen BH, et al. Aerobic interval training reduces the burden of atrial fibrillation in the short term: a randomized trial. Circulation 2016;133:466-73.
- Pathak RK, Elliott A, Middeldorp ME, et al. Impact of CARDIOrespiratory FITness on Arrhythmia Recurrence in Obese Individuals With Atrial Fibrillation: The CARDIO-FIT Study. J Am Coll Cardiol 2015;66:985-96.
- Andersen K, Farahmand B, Ahlbom A, et al. Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study. Eur Heart J 2013;34:3624-31.
- Molina L, Mont L, Marrugat J, et al. Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace 2008;10:618-23.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Sports and Exercise Cardiology, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Adrenergic Agents, Anti-Arrhythmia Agents, Atrial Fibrillation, Atrial Flutter, Athletes, Atrial Pressure, Catheter Ablation, Heart Atria, Heart Conduction System, Heart Rate, Pulmonary Veins, Risk Assessment, Sports
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