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Atrial Fibrillation

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Other Names

  • "A-fib"
  • AF


  • Rapid, irregularly, irregular heartbeat with chaotic and non-synchronous atrial activity
  • Can be characterized by acute onset atrial fibrillation without prior occurrence, chronic or persistent atrial fibrillation, or paroxysmal atrial fibrillation



  • Incidence of 0.003% at age 55 in males with an increase to 0.038% at age 94. For women, an incidence of 0.002% at age 55 with an increase to 0.0325% at age 94% [1]
  • A systematic review demonstrated that 3-6% of patients admitted from emergency rooms in the United Kingdom had atrial fibrillation and of those admits 40% were novel diagnoses [2]
  • In athletes, atrial fibrillation is on average five times more prevalent than in the general population and tends to occur mostly in individuals who are endurance trained [3]
    • 5-10% of marathon runners suffered from atrial fibrillation [4]


  • Electrophysiologic
    • High frequency excitation of the atrium due to ectopic firing, or reentry, leads to irregular atrial contraction. This results in asynchronized ventricular excitation and contraction [5]
  • Pro-inflammatory and Structural
    • In highly trained athletes, development of atrial fibrillation is thought to be due to a pro-inflammatory cytokines response to damaged muscle mass
    • This reduces glycogen stores and disrupts the energy balance between myocardial cell membranes and electrolytes leading to myocardial cell death [6] [3]


  • There is a documented direct correlation between paroxysmal atrial fibrillation and duration and intensity of exercise in athletes with activity for >10 hours per week for > 10 years significantly increases the risk of disease
    • This may be due to possible development of dilated cardiomyopathy

Risk Factors

  • Acute myocardial infarction
  • Acute alcohol use
  • Age - older individuals are at increased risk of atrial fibrillation
  • Male sex
  • Various cardiac diseases including ischemic heart disease, hypertension, heart failure, cardiac valvular disease
  • Thyroid disorders
  • Paroxysmal atrial fibrillation is more common in athletes [2]
  • Stimulant drug use
  • Sleep apnea

Differential Diagnosis

Clinical Features

  • General: Physical Exam Heart
  • History
    • Dizziness
    • Syncope
    • Dyspnea
    • Palpitations
  • Physical Exam
    • Irregularly, irregular heartbeat
    • Often tachycardic



  • Main method of diagnosis is 12 lead EKG and 24 hour holter monitoring
  • Demonstrates irregularly irregular rhythm

Transoesophageal Echocardiogram

  • May be used for evaluation of development of a clot in the atria


  • Acute
  • Chronic
    • sustained or recurrent Afib
    • may be categorized as paroxysmal, permanent or persistent
  • Paroxysmal
    • occurs intermittently with sinus rhythm
    • goal of care is maintenance of sinus rhythm
  • Permanent
    • goal of care is rate control with anti-thrombosis
  • Persistent
    • more sustained than paroxysmal
    • must be terminated with medications or cardioversion [2]



  • More than 50% of people with Israel fibrillation revert within 24 to 48 hours
  • Acute atrial fibrillation decreases cardiac output by 10 to 20% [2]


  • Cessation of physical activity
  • Antiarrythmic
    • β-blockers such as Sotalol are used as background therapy
      • Can prevent tachycardia and relaspe of Afib after ablation
    • Flecainide may be used
      • Ion-channel locker such as Propafenone and Disopyramide are contraindicated in sports performance due to the high risk of death [3]
  • Anticoagulants
    • should be used pending risk of bleeding in patients with a CHA2DS2-VASc score of >1 [7]


  • Catheter ablation of tacharrhythmic zones
    • Preferred method due to contraindications of antiarrhythmics and β-blockers in sports
    • High efficiency [3]

Rehab and Return to Play


  • Due to likelihood of developing overtraining syndrome, it is recommended to improve sleep and stress in addition to pharmacologic treatment before returning to play

Return to Play

  • Patients with treated atrial fibrillation may be allowed to return in the setting of
    • Absence of paroxysms for 3 months following drug therapy OR
    • Maintenance of sinus rhythm for one month follow ablation [3]
  • Individuals who are symptomatic and unable to restore sinus rhythm cannot be allowed to continue sports [8]


See Also


  1. Schnabel RB, Sullivan LM, Levy D, et al. Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study. Lancet. 2009;373(9665):739‐745. doi:10.1016/S0140-6736(09)60443-8
  2. 2.0 2.1 2.2 2.3 Lip GY, Apostolakis S. Atrial fibrillation (acute onset). BMJ Clin Evid. 2014;2014:0210. Published 2014 Nov 27.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Achkasov E, Bondarev S, Smirnov V, et al. Atrial Fibrillation in Athletes-Features of Development, Current Approaches to the Treatment, and Prevention of Complications. Int J Environ Res Public Health. 2019;16(24):4890. Published 2019 Dec 4. doi:10.3390/ijerph16244890
  4. Sharma S. Reloaded: Searching for the perfect dose of exercise?; Proceedings of the Davos Congressos; Davos, Switzerland. 23–26 January 2018.
  5. Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial Fibrillation: Epidemiology, Pathophysiology, and Clinical Outcomes. Circ Res. 2017;120(9):1501‐1517. doi:10.1161/CIRCRESAHA.117.309732
  6. Stiefel EC, Field L, Replogle W, McIntyre L, Igboechi O, Savoie FH 3rd. The Prevalence of Obesity and Elevated Blood Pressure in Adolescent Student Athletes From the State of Mississippi. Orthop J Sports Med. 2016;4(2):2325967116629368. Published 2016 Feb 19. doi:10.1177/2325967116629368
  7. Zipes D.P., Maron B.J. 36th Bethesda Conference. introduction: eligibility recommendations for competitive athletes with cardiovascular abnormalities—general considerations. J. Am. Coll. Cardiol. 2005;45:1318–1321.
  8. Wheeler M.T., Heidenreich P.A., Froelicher V.F., Hlatky M.A., Ashley E.A. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann. Intern. Med. 2010;152:276–286. doi: 10.7326/0003-4819-152-5-201003020-00005.
Created by:
John Kiel on 13 June 2019 09:18:20
Last edited:
21 May 2020 00:58:54