A growing body of evidence suggests that both atrial fibrillation (AF) and right ventricular arrhythmia can be the result of intense exercise among highly trained athletes
The risk of AF conferred by exercise progressively increases with the intensity of exercise
Parasympathetic tone enhancement and atrial structural remodelling (that is, atrial dilatation and fibrosis) are progressively being recognized as contributors to increased exercise-induced proarrhythmogenic risk
The most appropriate approach for treating exercise-induced AF remains unknown
The evidence for a pure exercise-induced arrhythmogenic right ventricular cardiomyopathy (ARVC) is limited, but several studies have indicated that regular exercise is an important promoter of ARVC progression
For athletes who fulfil ARVC criteria, guidelines published by scientific societies prohibit competitive sports and encourage avoidance of high-intensity dynamic sports in general
The cardiovascular benefits of physical activity are indisputable. Nevertheless, growing evidence suggests that both atrial fibrillation and right ventricular arrhythmia can be caused by intense exercise in some individuals. Exercise-induced atrial fibrillation is most commonly diagnosed in middle-aged, otherwise healthy men who have been engaged in endurance training for >10 years, and is mediated by atrial dilatation, parasympathetic enhancement, and possibly atrial fibrosis. Cardiac ablation is evolving as a first-line tool for athletes with exercise-induced arrhythmia who are eager to remain active. The relationship between physical activity and right ventricular arrhythmia is complex and involves genetic and physical factors that, in a few athletes, eventually lead to right ventricular dilatation, followed by subsequent myocardial fibrosis and lethal ventricular arrhythmias. Sinus bradycardia and atrioventricular conduction blocks are common in athletes, most of whom remain asymptomatic, although incomplete reversibility has been shown after exercise cessation. In this Review, we summarize the evidence supporting the existence of exercise-induced arrhythmias and discuss the specific considerations for the clinical management of these patients.
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Eijsvogels, T. M. H., Fernandez, A. B. & Thompson, P. D. Are there deleterious cardiac effects of acute and chronic endurance exercise? Physiol. Rev. 96, 99–125 (2016).
Siscovick, D. S., Weiss, N. S., Fletcher, R. H. & Lasky, T. The incidence of primary cardiac arrest during vigorous exercise. N. Engl. J. Med. 311, 874–877 (1984).
Harmon, K. G. et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: a decade in review. Circulation 132, 10–19 (2015).
Corrado, D., Basso, C., Rizzoli, G., Schiavon, M. & Thiene, G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J. Am. Coll. Cardiol. 42, 1959–1963 (2003).
Maron, B. J. et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 276, 199–204 (1996).
Corrado, D. et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 296, 1593–1601 (2006).
Mont, L. et al. Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: position paper from the EHRA and the EACPR, Q2 Q3 branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE. Europace. Europace(in press).
Karjalainen, J., Kujala, U. M., Kaprio, J., Sarna, S. & Viitasalo, M. Lone atrial fibrillation in vigorously exercising middle aged men: case–control study. BMJ 316, 1784–1785 (1998).
Mont, L. et al. Long-lasting sport practice and lone atrial fibrillation. Eur. Heart J. 23, 477–482 (2002).
Heidbüchel, H. et al. High prevalence of right ventricular involvement in endurance athletes with ventricular arrhythmias. Role of an electrophysiologic study in risk stratification. Eur. Heart J. 24, 1473–1480 (2003).
Armstrong, M. E. G. et al. Frequent physical activity may not reduce vascular disease risk as much as moderate activity: large prospective study of women in the United Kingdom. Circulation 131, 721–729 (2015).
January, C. T. 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. 64, 2246–2280 (2014).
Guasch, E. & Nattel, S. CrossTalk proposal: prolonged intense exercise training does lead to myocardial damage. J. Physiol. 591, 4939–4941 (2013).
Andersson, T. et al. All-cause mortality in 272 186 patients hospitalized with incident atrial fibrillation 1995–2008: a Swedish nationwide long-term case–control study. Eur. Heart J. 34, 1061–1067 (2013).
Calvo, N. et al. Emerging risk factors and the dose–response relationship between physical activity and lone atrial fibrillation: a prospective case–control study. Europace 18, 57–63 (2016).
Ruiz, J. R., Joyner, M. & Lucia, A. CrossTalk opposing view: prolonged intense exercise does not lead to cardiac damage. J. Physiol. 591, 4943–4945 (2013).
Strath, S. J. et al. Guide to the assessment of physical activity: clinical and research applications: a scientific statement from the American Heart Association. Circulation 128, 2259–2279 (2013).
Molina, L. et al. Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace 10, 618–623 (2008).
Baldesberger, S. et al. Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists. Eur. Heart J. 29, 71–78 (2008).
Grimsmo, J., Grundvold, I., Maehlum, S. & Arnesen, H. High prevalence of atrial fibrillation in long-term endurance cross-country skiers: echocardiographic findings and possible predictors — a 28–30 years follow-up study. Eur. J. Cardiovasc. Prev. Rehabil. 17, 100–105 (2010).
Andersen, K. et al. Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study. Eur. Heart J. 34, 3624–3631 (2013).
Aizer, A. et al. Relation of vigorous exercise to risk of atrial fibrillation. Am. J. Cardiol. 103, 1572–1577 (2009).
Thelle, D. S. et al. Resting heart rate and physical activity as risk factors for lone atrial fibrillation: a prospective study of 309 540 men and women. Heart 99, 1755–1760 (2013).
Drca, N., Wolk, A., Jensen-Urstad, M. & Larsson, S. C. Atrial fibrillation is associated with different levels of physical activity levels at different ages in men. Heart 100, 1037–1042 (2014).
Andersen, K. et al. Exercise capacity and muscle strength and risk of vascular disease and arrhythmia in 1.1 million young Swedish men: cohort study. BMJ 351, h4543 (2015).
Qureshi, W. T. et al. Cardiorespiratory fitness and risk of incident atrial fibrillation: results from the Henry Ford Exercise Testing (FIT) Project. Circulation 131, 1827–1834 (2015).
Mozaffarian, D., Furberg, C. D., Psaty, B. M. & Siscovick, D. Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study. Circulation 118, 800–807 (2008).
Bapat, A. et al. Relation of physical activity and incident atrial fibrillation (from the Multi-Ethnic Study of Atherosclerosis). Am. J. Cardiol. 116, 883–888 (2015).
Pathak, R. K. 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. 64, 2222–2231 (2014).
Pathak, R. K. et al. Long-term effect of goal-directed weight management in an atrial fibrillation cohort: a long-term follow-up study (LEGACY). J. Am. Coll. Cardiol. 65, 2159–2169 (2015).
Pathak, R. K. et al. Impact of cardiorespiratory fitness on arrhythmia recurrence in obese individuals with atrial fibrillation: the CARDIO-FIT study. J. Am. Coll. Cardiol. 66, 985–996 (2015).
Malmo, V. et al. Aerobic interval training reduces the burden of atrial fibrillation in the short term: a randomized trial. Circulation 133, 466–473 (2016).
Edelmann, F. et al. Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study. J. Am. Coll. Cardiol. 58, 1780–1791 (2011).
Frost, L., Frost, P. & Vestergaard, P. Work related physical activity and risk of a hospital discharge diagnosis of atrial fibrillation or flutter: the Danish Diet, Cancer, and Health Study. Occup. Environ. Med. 62, 49–53 (2005).
Morseth, B. et al. Physical activity, resting heart rate, and atrial fibrillation: the Tromsø Study. Eur. Heart J. 37, 2307–2313 (2016).
Claessen, G. et al. Long-term endurance sport is a risk factor for development of lone atrial flutter. Heart 97, 918–922 (2011).
Myrstad, M. et al. Effect of years of endurance exercise on risk of atrial fibrillation and atrial flutter. Am. J. Cardiol. 114, 1229–1233 (2014).
Drca, N., Wolk, A., Jensen-Urstad, M. & Larsson, S. C. Physical activity is associated with a reduced risk of atrial fibrillation in middle-aged and elderly women. Heart 101, 1627–1630 (2015).
Mont, L. et al. Physical activity, height, and left atrial size are independent risk factors for lone atrial fibrillation in middle-aged healthy individuals. Europace 10, 15–20 (2008).
Myrstad, M., Aarønæs, M., Graff-Iversen, S., Nystad, W. & Ranhoff, A. H. Does endurance exercise cause atrial fibrillation in women? Int. J. Cardiol. 184, 431–432 (2015).
Azarbal, F. et al. Obesity, physical activity, and their interaction in incident atrial fibrillation in postmenopausal women. J. Am. Heart Assoc.3, e001127 (2014).
Everett, B. M. et al. Physical activity and the risk of incident atrial fibrillation in women. Circ. Cardiovasc. Qual. Outcomes 4, 321–327 (2011).
Zhu, W.-G. et al. Sex differences in the association between regular physical activity and incident atrial fibrillation: a meta-analysis of 13 prospective studies. Clin. Cardiol. 39, 360–367 (2016).
Guasch, E. & Mont, L. Exercise, sex and atrial fibrillation: arrhythmogenesis beyond Y-chromosome? Heart 101, 1607–1609 (2015).
Myrstad, M. et al. Increased risk of atrial fibrillation among elderly Norwegian men with a history of long-term endurance sport practice. Scand. J. Med. Sci. Sports 24, e238–e244 (2014).
Van Buuren, F. et al. The occurrence of atrial fibrillation in former top-level handball players above the age of 50. Acta Cardiol. 67, 213–220 (2012).
Calvo, N. et al. Improved outcomes and complications of atrial fibrillation catheter ablation over time: learning curve, techniques, and methodology. Rev. Esp. Cardiol. (Engl. Ed.) 65, 131–138 (2012).
Pelliccia, A. et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J. Am. Coll. Cardiol. 46, 690–696 (2005).
Guasch, E. & Mont, L. Exercise and the heart: unmasking Mr. Hyde. Heart 100, 999–1000 (2014).
Mont, L., Brugada, J. & Elosua, R. Letter by Mont et al regarding article, 'Physical activity and incidence of atrial fibrillation in older adults: the Cardiovascular Health Study'. Circulation 119, e195; author reply e196 (2009).
Gabrielli, L. et al. Differential atrial performance at rest and exercise in athletes: potential trigger for developing atrial dysfunction? Scand. J. Med. Sci. Sports http://dx.doi.org/10.1111/sms.12610 (2016).
Khan, H. et al. Cardiorespiratory fitness and atrial fibrillation: a population-based follow-up study. Heart Rhythm 12, 1424–1430 (2015).
Coote, J. H. & White, M. J. CrossTalk proposal: bradycardia in the trained athlete is attributable to high vagal tone. J. Physiol. 593, 1745–1747 (2015).
D'Souza, A., Sharma, S. & Boyett, M. R. CrossTalk opposing view: bradycardia in the trained athlete is attributable to a downregulation of a pacemaker channel in the sinus node. J. Physiol. 593, 1749–1751 (2015).
Shen, M. J. et al. Neural mechanisms of atrial arrhythmias. Nat. Rev. Cardiol. 9, 30–39 (2012).
Hoogsteen, J., Schep, G., Van Hemel, N. M. & Van Der Wall, E. E. Paroxysmal atrial fibrillation in male endurance athletes. A 9-year follow up. Europace 6, 222–228 (2004).
Wilhelm, M. et al. Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes. Am. J. Cardiol. 108, 580–585 (2011).
Guasch, E. et al. Atrial fibrillation promotion by endurance exercise: demonstration and mechanistic exploration in an animal model. J. Am. Coll. Cardiol. 62, 68–77 (2013).
Zou, R., Kneller, J., Leon, L. J. & Nattel, S. Substrate size as a determinant of fibrillatory activity maintenance in a mathematical model of canine atrium. Am. J. Physiol. Heart Circ. Physiol. 289, H1002–H1012 (2005).
Nattel, S. et al. Early management of atrial fibrillation to prevent cardiovascular complications. Eur. Heart J. 35, 1448–1456 (2014).
Burstein, B. & Nattel, S. Atrial fibrosis: mechanisms and clinical relevance in atrial fibrillation. J. Am. Coll. Cardiol. 51, 802–809 (2008).
Benito, B. et al. Cardiac arrhythmogenic remodeling in a rat model of long-term intensive exercise training. Circulation 123, 13–22 (2011).
Aschar-Sobbi, R. et al. Increased atrial arrhythmia susceptibility induced by intense endurance exercise in mice requires TNFα. Nat. Commun. 6, 6018 (2015).
Lindsay, M. M. & Dunn, F. G. Biochemical evidence of myocardial fibrosis in veteran endurance athletes. Br. J. Sports Med. 41, 447–452 (2007).
Ho, J. E. et al. Galectin 3 and incident atrial fibrillation in the community. Am. Heart J. 167, 729–734.e1 (2014).
Baggish, A. L. et al. Dynamic regulation of circulating microRNA during acute exhaustive exercise and sustained aerobic exercise training. J. Physiol. 589, 3983–3994 (2011).
Wilhelm, M. et al. Long-term cardiac remodeling and arrhythmias in nonelite marathon runners. Am. J. Cardiol. 110, 129–135 (2012).
D'Ascenzi, F. et al. P-wave morphology is unaffected by training-induced biatrial dilatation: a prospective, longitudinal study in healthy athletes. Int. J. Cardiovasc. Imaging 32, 407–415 (2016).
Scott, C. C., Leier, C. V., Kilman, J. W., Vasko, J. S. & Unverferth, D. V. The effect of left atrial histology and dimension on P wave morphology. J. Electrocardiol. 16, 363–366 (1983).
Sanz-de la Garza, M. et al. Acute, exercise dose-dependent impairment in atrial performance during an endurance race: 2D ultrasound speckle-tracking strain analysis. JACC Cardiovasc. Imaging http://dx.doi.org/10.1016/j.jcmg.2016.03.016 (2016).
Gay-Jordi, G. et al. Losartan prevents heart fibrosis induced by long-term intensive exercise in an animal model. PLoS ONE 8, e55427 (2013).
Leischik, R., Spelsberg, N., Niggemann, H., Dworrak, B. & Tiroch, K. Exercise-induced arterial hypertension — an independent factor for hypertrophy and a ticking clock for cardiac fatigue or atrial fibrillation in athletes? F1000Res. 3, 105 (2014).
Trachsel, L. D., Carlen, F., Brugger, N., Seiler, C. & Wilhelm, M. Masked hypertension and cardiac remodeling in middle-aged endurance athletes. J. Hypertens. 33, 1276–1283 (2015).
Gabrielli, L. et al. Atrial functional and geometrical remodeling in highly trained male athletes: for better or worse? Eur. J. Appl. Physiol. 114, 1143–1152 (2014).
La Gerche, A. et al. Relationship between inflammatory cytokines and indices of cardiac dysfunction following intense endurance exercise. PLoS ONE 10, 1–15 (2015).
Oláh, A. et al. Cardiac effects of acute exhaustive exercise in a rat model. Int. J. Cardiol. 182, 258–266 (2015).
Wilhelm, M. et al. Inflammation and atrial remodeling after a mountain marathon. Scand. J. Med. Sci. Sport. 24, 519–525 (2014).
Walsh, N. P. et al. Position statement part one: immune function and exercise. Exerc. Immunol. Rev. 17, 6–63 (2011).
Hellard, P., Avalos, M., Guimaraes, F., Toussaint, J. F. & Pyne, D. B. Training-related risk of common illnesses in elite swimmers over a 4-yr period. Med. Sci. Sports Exerc. 47, 698–707 (2015).
Nieman, D. C., Johanssen, L. M., Lee, J. W. & Arabatzis, K. Infectious episodes in runners before and after the Los Angeles Marathon. J. Sports Med. Phys. Fitness 30, 316–328 (1990).
Mahrholdt, H. et al. Presentation, patterns of myocardial damage, and clinical course of viral myocarditis. Circulation 114, 1581–1590 (2006).
Begieneman, M. P. V. et al. Ventricular myocarditis coincides with atrial myocarditis in patients. Cardiovasc. Pathol. 25, 141–148 (2016).
Kiel, R. J., Smith, F. E., Chason, J., Khatib, R. & Reyes, M. P. Coxsackievirus B3 myocarditis in C3H/HeJ mice: description of an inbred model and the effect of exercise on virulence. Eur. J. Epidemiol. 5, 348–350 (1989).
Lau, D. H. et al. Atrial fibrillation and anabolic steroid abuse. Int. J. Cardiol. 117, e86–e87 (2007).
Akçakoyun, M. et al. Long-Term anabolic androgenic steroid use is associated with increased atrial electromechanical delay in male bodybuilders. Biomed. Res. Int. 451520 (2014).
Agulló-Calatayud, V., González-Alcaide, G., Valderrama- Zurián, J. C. & Aleixandre-Benavent, R. Consumption of anabolic steroids in sport, physical activity and as a drug of abuse: an analysis of the scientific literature and areas of research. Br. J. Sports Med. 42, 103–109 (2008).
Walters, T. E. et al. Acute atrial stretch results in conduction slowing and complex signals at the pulmonary vein to left atrial junction: insights into the mechanism of pulmonary vein arrhythmogenesis. Circ. Arrhythm. Electrophysiol. 7, 1189–1197 (2014).
Ueda, N., Yamamoto, M., Honjo, H., Kodama, I. & Kamiya, K. The role of gap junctions in stretch-induced atrial fibrillation. Cardiovasc. Res. 104, 364–370 (2014).
Furlanello, F. et al. Atrial fibrillation in elite athletes. J. Cardiovasc. Electrophysiol. 9, S63–S68 (1998).
Myrstad, M. et al. Physical activity, symptoms, medication and subjective health among veteran endurance athletes with atrial fibrillation. Clin. Res. Cardiol. 105, 154–161 (2015).
Taggar, J. S., Coleman, T., Lewis, S., Heneghan, C. & Jones, M. Accuracy of methods for diagnosing atrial fibrillation using 12-lead ECG: a systematic review and meta-analysis. Int. J. Cardiol. 184, 175–183 (2015).
Hållmarker, U. et al. Risk of recurrent stroke and death after first stroke in long-distance ski race participants. J. Am. Heart Assoc. 4, e002469 (2015).
Benjamin, E. J. et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98, 946–952 (1998).
Potpara, T. S. et al. A 12-year follow-up study of patients with newly diagnosed lone atrial fibrillation. Implications of arrhythmia progression on prognosis: the Belgrade Atrial Fibrillation Study. Chest 141, 339–347 (2012).
Kim, E.-J. et al. Atrial fibrillation without comorbidities: prevalence, incidence and prognosis (from the Framingham Heart Study). Am. Heart J. 177, 138–144 (2016).
Heidbüchel, H. et al. Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter. Int. J. Cardiol. 107, 67–72 (2006).
Sussman, S., Lisha, N. & Griffiths, M. Prevalence of the addictions: a problem of the majority or the minority? Eval. Health Prof. 34, 3–56 (2011).
Giacomantonio, N. B., Bredin, S. S. D., Foulds, H. J. A. & Warburton, D. E. R. A systematic review of the health benefits of exercise rehabilitation in persons living with atrial fibrillation. Can. J. Cardiol. 29, 483–491 (2013).
Calvo, N. et al. Efficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes. Europace 12, 30–36 (2010).
Koopman, P. et al. Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation. Europace 13, 1386–1393 (2011).
Furlanello, F. et al. Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition. J. Cardiovasc. Electrophysiol. 19, 457–462 (2008).
Palatini, P. et al. Prevalence and possible mechanisms of ventricular arrhythmias in athletes. Am. Heart J. 110, 560–567 (1985).
Jensen-Urstad, K., Bouvier, F., Saltin, B. & Jensen-Urstad, M. High prevalence of arrhythmias in elderly male athletes with a lifelong history of regular strenuous exercise. Heart 79, 161–164 (1998).
Pelliccia, A. et al. Remodeling of left ventricular hypertrophy in elite athletes after long-term deconditioning. Circulation 105, 944–949 (2002).
Ector, J. et al. Reduced right ventricular ejection fraction in endurance athletes presenting with ventricular arrhythmias: a quantitative angiographic assessment. Eur. Heart J. 28, 345–353 (2007).
La Gerche, A. et al. Lower than expected desmosomal gene mutation prevalence in endurance athletes with complex ventricular arrhythmias of right ventricular origin. Heart 96, 1268–1274 (2010).
Ruwald, A. C. et al. Association of competitive and recreational sport participation with cardiac events in patients with arrhythmogenic right ventricular cardiomyopathy: results from the North American multidisciplinary study of arrhythmogenic right ventricular cardiomyopathy. Eur. Heart J. 36, 1735–1743 (2015).
Sawant, A. C. et al. Exercise has a disproportionate role in the pathogenesis of arrhythmogenic right ventricular dysplasia/cardiomyopathy in patients without desmosomal mutations. J. Am. Heart Assoc. 3, e001471 (2014).
James, C. a et al. Exercise increases age-related penetrance and arrhythmic risk in arrhythmogenic right ventricular dysplasia/cardiomyopathy associated desmosomal mutation carriers. J. Am. Coll. Cardiol. 62 1290–1297 (2013).
Saberniak, J. et al. Vigorous physical activity impairs myocardial function in patients with arrhythmogenic right ventricular cardiomyopathy and in mutation positive family members. Eur. J. Heart Fail. 16, 1337–1344 (2014).
Hättasch, R. et al. Galectin-3 increase in endurance athletes. Eur. J. Prev. Cardiol. 21, 1192–1199 (2014).
Dello Russo, A. et al. Concealed cardiomyopathies in competitive athletes with ventricular arrhythmias and an apparently normal heart: role of cardiac electroanatomical mapping and biopsy. Heart Rhythm 8, 1915–1922 (2011).
Ambale-Venkatesh, B. & Lima, J. A. Cardiac MRI: a central prognostic tool in myocardial fibrosis. Nat. Rev. Cardiol. 12, 18–29 (2014).
Bohm, P. et al. Right and left ventricular function and mass in male elite master athletes: a controlled contrast-enhanced cardiovascular magnetic resonance study. Circulation 133, 1927–1935 (2016).
La Gerche, A. et al. Disproportionate exercise load and remodeling of the athlete's right ventricle. Med. Sci. Sports Exerc. 43, 974–981 (2011).
Gaudreault, V. et al. Transient myocardial tissue and function changes during a marathon in less fit marathon runners. Can. J. Cardiol. 29, 1269–1276 (2013).
Breuckmann, F. et al. Myocardial late gadolinium enhancement: prevalence, pattern, and prognostic relevance in marathon runners. Radiology 251, 50–57 (2009).
Möhlenkamp, S. et al. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur. Heart J. 29, 1903–1910 (2008).
La Gerche, A. et al. Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur. Heart J. 33, 998–1006 (2012).
Elliott, A. D. & La Gerche, A. The right ventricle following prolonged endurance exercise: are we overlooking the more important side of the heart? A meta-analysis. Br. J. Sports Med. 49, 724–729 (2014).
Sanz de la Garza, M. et al. Inter-individual variability in right ventricle adaptation after an endurance race. Eur. J. Prev. Cardiol. 23, 1114–1124 (2015).
Casella, M. et al. Ventricular arrhythmias induced by long-term use of ephedrine in two competitive athletes. Heart Vessels 30, 280–283 (2015).
La Gerche, A. et al. Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes. Eur. Heart J. 36, 1998–2010 (2015).
Perrin, M. J. et al. Exercise testing in asymptomatic gene carriers exposes a latent electrical substrate of arrhythmogenic right ventricular cardiomyopathy. J. Am. Coll. Cardiol. 62, 1772–1779 (2013).
Priori, S. G. et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the task force for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur. Heart J. 36, 2793–2867 (2015).
Corrado, D. et al. Treatment of arrhythmogenic right ventricular cardiomyopathy/dysplasia: an international task force consensus statement. Eur. Heart J. 36, 3227–3237 (2015).
Brosnan, M. et al. Comparison of frequency of significant electrocardiographic abnormalities in endurance versus nonendurance athletes. Am. J. Cardiol. 113, 1567–1573 (2014).
Sharma, S. et al. Electrocardiographic changes in 1000 highly trained junior elite athletes. Br. J. Sports Med. 33, 319–324 (1999).
Senturk, T. et al. Cardiac pauses in competitive athletes: a systematic review examining the basis of current practice recommendations. Europace http://dx.doi.org/10.1093/europace/euv373 (2015).
Danson, E. J. F. & Paterson, D. J. Enhanced neuronal nitric oxide synthase expression is central to cardiac vagal phenotype in exercise-trained mice. J. Physiol. 546, 225–232 (2003).
Katona, P. G., McLean, M., Dighton, D. H. & Guz, A. Sympathetic and parasympathetic cardiac control in athletes and nonathletes at rest. J. Appl. Physiol. 52, 1652–1657 (1982).
Stein, R., Medeiros, C. M., Rosito, G. A., Zimerman, L. I. & Ribeiro, J. P. Intrinsic sinus and atrioventricular node electrophysiologic adaptations in endurance athletes. J. Am. Coll. Cardiol. 39, 1033–1038 (2002).
D'Souza, A. et al. Exercise training reduces resting heart rate via downregulation of the funny channel HCN4. Nat. Commun. 5, 3775 (2014).
Santos, M., Pinheiro-Vieira, A. & Hipólito-Reis, A. Bradycardia in the athlete: don't always blame the autonomic system! Europace 15, 1650 (2013).
Bjørnstad, H. H. et al. Long-term assessment of electrocardiographic and echocardiographic findings in Norwegian elite endurance athletes. Cardiology 112, 234–241 (2009).
Serra-Grima, R., Puig, T., Doñate, M., Gich, I. & Ramon, J. Long-term follow-up of bradycardia in elite athletes. Int. J. Sports Med. 29, 934–937 (2008).
Zipes, D. P. et al. 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. 66, 2412–2423 (2015).
Brignole, M. et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 15, 1070–1118 (2013).
Fabritz, L. et al. Expert consensus document: defining the major health modifiers causing atrial fibrillation: a roadmap to underpin personalized prevention and treatment. Nat. Rev. Cardiol. 13, 230–237 (2015).
Woodward, A., Tin Tin, S., Doughty, R. N. & Ameratunga, S. Atrial fibrillation and cycling: six year follow-up of the Taupo bicycle study. BMC Public Health 15, 23 (2015).
Elosua, R. et al. Sport practice and the risk of lone atrial fibrillation: a case–control study. Int. J. Cardiol. 108, 332–337 (2006).
Ofman, P. et al. Regular physical activity and risk of atrial fibrillation: a systematic review and meta-analysis. Circ. Arrhythm. Electrophysiol. 6, 252–256 (2013).
Abdulla, J. & Nielsen, J. R. Is the risk of atrial fibrillation higher in athletes than in the general population? A systematic review and meta-analysis. Europace 11, 1156–1159 (2009).
Kwok, C. S., Anderson, S. G., Myint, P. K., Mamas, M. A. & Loke, Y. K. Physical activity and incidence of atrial fibrillation: a systematic review and meta-analysis. Int. J. Cardiol. 177, 467–476 (2014).
Moncayo-Arlandi, J. et al. Molecular disturbance underlies to arrhythmogenic cardiomyopathy induced by transgene content, age and exercise in a truncated PKP2 mouse model. Hum. Mol. Genet. http://dx.doi.org/10.1093/hmg/ddw213 (2016).
Cruz, F. M. et al. Exercise triggers ARVC phenotype in mice expressing a disease-causing mutated version of human plakophilin-2. J. Am. Coll. Cardiol. 65, 1438–1450 (2015).
Kirchhof, P. et al. Age- and training-dependent development of arrhythmogenic right ventricular cardiomyopathy in heterozygous plakoglobin-deficient mice. Circulation 114, 1799–1806 (2006).
Huxley, R. R. et al. Physical activity, obesity, weight change, and risk of atrial fibrillation the atherosclerosis risk in communities study. Circ. Arrhythm. Electrophysiol. 7, 620–625 (2014).
The authors have received funding from the European Union's Horizon 2020 Research and Innovation Programme under grant agreement 633196 (CATCH ME project) and from Instituto de Salud Carlos III — Fondo de Investigaciones Sanitarias (PI13/01580 and PI16/00703).
The authors declare no competing financial interests.
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Guasch, E., Mont, L. Diagnosis, pathophysiology, and management of exercise-induced arrhythmias. Nat Rev Cardiol 14, 88–101 (2017). https://doi.org/10.1038/nrcardio.2016.173
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