Atrial fibrillation in athletes: towards a changing therapeutic approach in the era of catheter ablation

Background The Prevalence of atrial fibrillation (AF) is increasing and its incidence in professional and amateur athletes seems higher than in the general population (OR=2–10 after adjustment for other risk factors). A U shaped relationship of physical activity with incident AF suggests that the positive antiarrhythmic effects of sport are partially negated by prolonged heavy endurance exercise. AF is also more prevalent in middle-aged former competitive athletes. Design A review of the literature of AF in athletes is presented. AF may be due to sympathetic activity, volume load during exercise, vagotonia at rest but also atrial hypertrophy and dilatation. Anticoagulation cannot be used in sporting activities with a risk of bodily collision. Rate control during AF is difficult to reach in athletes: -blockers are not well tolerated or even prohibited in some competitive sports, and digoxin or calcium antagonists are poorly effective during exertion. In paroxysmal AF athletes, the flecainide or propafenone ‘pill-in the pocket approach’ can be used, but transient sport practice limitations ensue. Intervention Several reports of the new pulmonary vein catheter ablation have demonstrated encouraging results. Using radiofrequency current, the latter is as efficacious in lone AF amateur athletes as in controls. Representative examples from our AF ablation patient database will be presented. Conclusion A review of the literature and our own experience suggest that catheter ablation of AF in athletes will probably develop in the near future. This is also supported by the recent European guidelines which state that ‘where appropriate, AF ablation should be considered to prevent recurrent AF in athletes' without requiring prior drug therapy.