Arrhythmias in Athletes: Let's Make the Decision Together
Care of the Athletic Heart 2019
Dear Sports and Exercise Cardiology Enthusiasts:
Care of the Athletic Heart 2019 (CAH), directed by Matthew Martinez MD, and Jonathan Kim, MD, convened June 20-22 at the American College of Cardiology's Heart House in Washington, DC. The overflow capacity of attendees and number of live streaming participants exceeded 220 in total. In the next few weeks, we will post summaries of key sessions written by cardiology Fellows-in-Training (FIT). Most of them were presenters at CAH, and all are active in the Sports and Exercise Cardiology Section FIT Interest Group.
Thank you to the FITs for all their hard work. We hope you enjoy the summaries.
Eugene H Chung, MD, FACC
Editorial Team Lead, Sports & Exercise Cardiology Clinical Topic Collection
This session featured an engaging debate between Dr. Mark Link and Dr. Sanjay Sharma on the pros and cons of catheter ablation for atrial fibrillation (AF) in masters athletes. Outlined below are key points from their debate which, in the words of Dr. Paul Thompson, "had enough edge and humor for it to be one of the best debates I had ever witnessed."
The argument for early ablation for AF in masters athletes (Dr. Link):
- Catheter ablation provides greater freedom from AF than anti-arrhythmic drugs alone.1
- Systematic reviews of anti-arrhythmic drugs (especially Class 1a) show a signal towards increased mortality.2
- Although the recent CABANA (Catheter ABlation vs ANtiarrhythmic Drug Therapy in Atrial Fibrillation) trial showed that ablation is not superior to pharmacologic therapy for cardiovascular outcomes, the investigators used an intention-to-treat analysis despite the high crossover rate.3 Per-protocol analysis showed improved quality of life metrics with ablation. Furthermore, there was a very low complication rate in the approximately 1100 patients who underwent ablation.
- Ablation to treat AF is now recognized by both the North American and European Task Force committees and holds a Class 1A indication for symptomatic paroxysmal AF to improve AF symptoms in patients on anti-arrhythmic drugs.4,5
The argument for ablation to be performed only as a last resort for AF in masters athletes (Dr. Sharma):
- The estimated risk of death, heart failure and embolic stroke from AF is derived from the general population with a multitude of other risk factors and diseases. The risk of these complications is unknown in athletes with AF.
- Treatment of AF aims to reduce symptoms, risk of stroke and ventricular rates. However, athletes with AF typically have fewer symptoms than the general population, lower CHA2DS2-VASc scores and slower ventricular rates in AF.
- Although we do not fully understand the mechanism of AF in athletes, the suspected trigger in an endurance athlete is the high level of endurance exercise. A reduction in the exercise dose among this population may be the most appropriate intervention to reduce risk of recurrence of AF and burden of disease. It is possible ablation may provide athletes with false reassurance regarding their current exercise dose, which could lead to unknown long-term cardiovascular issues.
- There are only very limited data investigating the management of AF in athletes based on studies that were non-randomized and non-blinded. They showed a high fluoroscopic time, low success in maintaining sinus rhythm after 1 year, and frequent need for recurrent procedures which still did not guarantee a disease-free state.6,7
Despite their differing stances on catheter ablation, Drs. Link and Sharma agreed on the importance of excluding underlying causes of AF, assessing the risk of stroke and consideration of detraining. They also agreed that management of AF in the athlete, especially the masters athlete, must address modification of triggers of AF (e.g.. caffeine, alcohol, stimulants) and treatment of predisposing conditions (e.g., hypertension, diabetes, sleeping disorders).
Following the "debate of the century," Fellows-in-Training shared clinical cases of athletes with arrhythmias for the panel to discuss appropriate management strategies. Dr. Andrew Levy and Dr. Allison Zielinski continued with the theme of AF with additional cases of this disease in an athlete with hypertrophic cardiomyopathy and a veteran cyclist, respectively. These cases emphasized the need for shared decision-making to guide management of AF in athletes. Dr. Elizabeth Hill also presented a symptomatic athlete with Wolff-Parkinson-White syndrome, which highlighted the importance of recognizing concerning symptoms in this condition. Red flag symptoms should prompt full work-up with an exercise and electrophysiologic study to clarify and ablate the accessory pathway.
Finally, Dr. Guru Kowlgi ended the session with a case of bidirectional ventricular tachycardia in a recreational endurance athlete due to catecholaminergic polymorphic ventricular tachycardia. It was a rare moment when the panel and audience unanimously agreed that aggressive beta-blocker therapy should be the mainstay of treatment in this disease and that ICDs should only be used if syncope/ventricular tachycardia recurs despite medical therapy.
In sum, the session highlighted the challenges that are frequently encountered within sports cardiology and reviewed the heterogeneity of our approaches, emphasizing the need for more robust data on our athletes with arrhythmias.
- Tung R, Buch E, Shivkumar K. Catheter ablation of atrial fibrillation. Circulation 2012;126:223-9.
- Lafuente-Lafuente C, Longas-Tejero MA, Bergmann JF, Belmin J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev 2012:CD005049.
- Packer DL, Mark DB, Robb RA, et al. Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: the CABANA randomized clinical trial. JAMA 2019. [Epub ahead of print]
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014;64:e1-76.
- Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016;37:2893-962.
- Calvo N, Mont L, Tamborero D, et al. Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. Europace 2010;12:30-6.
- Koopman P, Nuyens D, Garweg C, et al. Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation. Europace 2011;13:1386-93.
Clinical Topics: Arrhythmias and Clinical EP, Cardio-Oncology, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Hypertension, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology
Keywords: Sports, Athletes, Anti-Arrhythmia Agents, Atrial Fibrillation, Tachycardia, Ventricular, Wolff-Parkinson-White Syndrome, Risk Factors, Research Personnel, Intention to Treat Analysis, Quality of Life, Catheter Ablation, Stroke, Heart Failure, Syncope, Cardiomyopathy, Hypertrophic, Hypertension, Diabetes Mellitus, Decision Making
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