Diagnosis, pathophysiology, and management of exercise-induced arrhythmias

Key Points

  • 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

Abstract

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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Figure 1: Evidence assessing the association between physical activity and risk of atrial fibrillation (AF).
Figure 2: Identification of individuals at risk of exercise-induced atrial fibrillation (AF).
Figure 3: U-shape relationship between exercise dose and risk of atrial fibrillation (AF).
Figure 4: Mechanisms potentially involved in exercise-induced atrial fibrillation (AF).
Figure 5: Proposed clinical approach in athletes at suspicion of atrial fibrillation (AF) and with diagnosed AF.
Figure 6: Proposed arrhythmogenic right ventricular cardiomyopathy (ARVC)-continuum in relation to exercise dose.
Figure 7: Proposed clinical approach to athletes with right ventricular arrhythmias.

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Acknowledgements

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).

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Both authors researched data for the article, substantially contributed to discussion of its content, and reviewed and edited the manuscript before submission. E.G. wrote the article.

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Correspondence to Eduard Guasch or Lluís Mont.

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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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