Exercise and atrial fibrillation

Exercise Training and Atrial Fibrillation

Atrial fibrillation (AF) is the most common clinical arrhythmia with a global burden that has increased progressively, contributing to rising hospitalizations and substantial healthcare demands.1–3 Although aging is an important contributor to the rising AF prevalence, key mechanistic promoters of AF include modifiable risk factors such as obesity, hypertension, diabetes mellitus, and obstructive sleep apnea.

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Exercise training and physical activity improve the management of hypertension and diabetes mellitus,4 assist in weight management,5 and improve cardiac structure and function.6 Surprisingly, despite these favorable modifications of arrhythmogenic risk factors, greater physical activity only modestly reduces incident AF rates.7,8 At the extreme end of the exercise spectrum, endurance athletes, who engage in the greatest volume of exercise training, encounter a risk of AF that rises significantly. Cohort studies provide estimates of AF risk in the endurance athlete population that range from a 2-9 to 7-fold10 elevation in incident AF risk. Until recently, the AF and exercise story has stopped here: that physically active individuals experience a small reduction in risk, but doing too much increases arrhythmia risk considerably, consistent with a classic J-shaped phenomenon. Perhaps, in part because of these findings and a misguided fear of promoting arrhythmias, there is a scarcity of data regarding the effects of exercise training in patients with nonpermanent AF.

In the current issue of Circulation, Malmo et al11 provide the results of their randomized, controlled trial, in which they compared a popular form of high-intensity exercise, aerobic interval training, with a control group who were not prescribed exercise. The authors randomly assigned 51 AF patients referred for catheter ablation to exercise or no exercise over 12 weeks, and recorded AF burden from implantable loop recorders as the primary study outcome. Notably, the authors demonstrate a significant reduction in AF burden in the exercise group, where the mean time in AF declined from 8.1% to 4.8%, with no significant change in the control group. Of the exercise group, 38% of patients experienced a decline in their arrhythmia burden in comparison with only 20% of the control group. Increased AF burden was more common in the control patients (64%) than in the exercise group (12%). Importantly, patients in the exercise group experienced fewer and less severe symptoms following the intervention, with no concomitant change in the control group. In comparison with controls, patients randomly assigned to exercise also increased their peak oxygen consumption (Vo2peak), cardiac function, and quality of life, while improving body mass index and blood lipids.

These are important and timely findings that are consistent with data from our group showing that gains in cardiorespiratory fitness are associated with significant abatement of arrhythmia burden both with and without rhythm control strategies.12 In our cohort of >300 symptomatic, overweight, and obese AF patients, each 1–metabolic equivalent incremental gain in fitness corresponded to a 9% reduction in AF recurrence over a 4-year follow-up. Taken together, these 2 studies provide empirical support for exercise training and physical activity as a key element in the treatment of patients with AF. Importantly, for those who remain concerned about potential arrhythmogenic effects of exercise, there is no evidence to suggest that exercise training within current guidelines exacerbates AF. This should not be surprising given the large differences in the dose of exercise engaged in by an AF patient in comparison with that practiced by the endurance athletes in which AF risk appears to be higher.

We commend the authors on their study, although there are several subtle points that should be raised to place these findings into context. First, as highlighted in their discussion, patients randomly assigned in this study were typically healthy with mild risk factor prevalence. As such, exercise training only modestly reduced body mass index and had no significant impact on blood pressure, MRI-derived left atrial size, or inflammation, all of which are independent arrhythmogenic risk factors. In comparison, we showed that long-term improvements in fitness resulted in significantly reduced blood pressure, inflammation, and left atrial size, while also improving blood lipid status and glycemic control. The majority of these risk factors were higher at baseline in our patients in comparison with those enrolled in the Malmo et al study. On the one hand, it is likely that the benefits of exercise may be understated within this reasonably healthy cohort, given its positive effect on risk factor profile. On the other hand, it is encouraging that exercise exerts antiarrhythmic benefits in the absence of large changes in other risk factors, thus suggesting an independent effect. Second, this study included only a 12-week intervention with 4-week follow-up period. Despite the favorable findings over this duration, it cannot be ascertained whether prescribing exercise training presents an effective long-term strategy in the treatment of AF.

Previous studies including lifestyle interventions with weight loss have shown clinically significant benefits in AF patients over a longer-term follow-up.13,14 This leaves open the question of whether supervised exercise training and its benefits can be maintained similarly beyond the 16-week period. In the post HF-ACTION15 era, there has been increasing skepticism regarding the efficacy of supervised exercise training as an achievable long-term strategy for the management of cardiovascular disease. In the HF-ACTION trial, initial gains from supervised exercise training over 3 months were diluted by a lack of adherence following the supervised intervention, thus resulting in only modest benefits at final follow-up. Future studies in patients with AF require longer-term interventions and follow-up, and alternative strategies for maintaining appropriate activity levels and exercise habits outside the clinic, as well.

The study of Malmo et al11 also provides some mechanistic insight into the benefit of exercise training for patients with AF. These findings show that exercise reduces AF burden in the absence of significant changes in left atrial size, blood pressure, and inflammation. Although body mass index and blood lipids were modestly improved, the primary mechanism(s) driving the benefit of exercise may not be apparent from these measures alone and instead may come from the direct effects on autonomic factors and intrinsic electrophysiological measures that require invasive procedures for assessment. In animal and human studies, AF risk factors such as hypertension16 and obesity17 are associated with atrial remodeling, characterized by conduction slowing, low atrial voltages, and increased interstitial fibrosis. A key question that remains to be answered is whether exercise training can independently reverse atrial remodeling or whether its effects are mediated via other pathways.

If exercise is to be accepted into the management strategy for patients with symptomatic AF, can we optimize the prescription? In this study, patients underwent aerobic interval training, in which they engage in four 4-minute bouts of high-intensity (commonly 85% to 95% peak heart rate) aerobic exercise, each interspersed by 3 minutes of active recovery. Previous studies from this center have shown the benefits of this form of exercise for heart failure18 and metabolic syndrome.19 In our clinic, we prescribe exercise up to 85% of peak heart rate for a total duration of 200 minutes per week, a strategy that leads to greater AF freedom in those who make significant gains in cardiorespiratory fitness.12 In the absence of comparative data of training modalities for AF patients, current recommendations should focus on prescribing forms of aerobic exercise that patients enjoy and are most likely to adhere to, rather than being overly specific. However, the current evidence supports the efficacy of aerobic exercise activities up to, or close to, peak heart rate if appropriate and achievable to the patient (Figure). Further studies will hopefully contribute to defining the optimal aerobic exercise dose for patients with AF and also establishing the role of resistance training within the exercise prescription.

Figure. Overview of existing knowledge regarding exercise training and atrial fibrillation. AF indicates atrial fibrillation; BP, blood pressure; and HR, heart rate.

Although the current study contributes long overdue data regarding exercise training in patients with AF, we should also be mindful of the patients who did not meet the enrolment criteria in this study. Malmo et al enrolled 51 patients from 313 screened for inclusion. Approximately 40% met the inclusion criteria of symptomatic, nonpermanent AF referred for first AF ablation, thus leaving 188 patients (60%) excluded. Previous studies have shown the benefits of exercise training on cardiorespiratory fitness and quality of life for those patients with permanent AF.20 However, we are left to postulate on whether exercise can provide specific benefits to the patients who are not candidates for AF ablation or who are undergoing repeat AF ablation. These patients likely include those with a more advanced atrial substrate, adding complexity to the arrhythmia management.

For those undergoing initial catheter ablation, we have also shown that weight loss and aggressive risk factor management before initial catheter ablation leads to a significant reduction in AF recurrences over a 3- to 4-year follow-up period, in comparison with usual care controls.13 This raises the prospect that exercise training prescribed within the periablation period may offer similar benefits by reducing long-term postablation arrhythmia recurrences, thus improving patient outcomes while simultaneously reducing healthcare demands and exposure to multiple procedures. Although this question is not addressed in the current study, future randomized, controlled trials are warranted to provide data regarding how exercise training may modulate ablation outcomes.

The results from this study require confirmation by larger trials with longer follow-up. However, this study presents an exciting development for the treatment of AF and adds to the rising wave of evidence showing that, in many patients, lifestyle change, including weight management and exercise alongside risk factor management, provides an effective front-line strategy to reduce AF symptoms and provide a potent antiarrhythmic benefit. We encourage clinicians to promote exercise, among other lifestyle modifications, to their patients in a bid (1) to dampen the burden of AF and its associated symptoms and (2) to decrease the heavy reliance on pharmaceutical and interventional strategies for arrhythmia management.

Sources of Funding

Dr Mahajan is supported by the Leo J. Mahar Lectureship from the University of Adelaide and by an Early Career Fellowship jointly funded by the National Health and Medical Research Council of Australia and the National Heart Foundation of Australia. Dr Pathak is supported by an Early Career Fellowship funded by the National Health and Medical Research Council of Australia. Dr Lau is supported by a Robert J. Craig Lectureship from the University of Adelaide. Dr Sanders is supported by a Practitioner Fellowship from the National Health and Medical Research Council of Australia and by the National Heart Foundation of Australia.


Dr Sanders reports having served on the advisory board of Biosense-Webster, Medtronic, CathRx, and St Jude Medical. Dr Sanders reports having received lecture and consulting fees from Biosense-Webster, Medtronic, St Jude Medical, and Boston Scientific. Dr Sanders reports having received research funding from Medtronic, St Jude Medical, Boston Scientific, Biotronik, and Sorin. The other authors report no conflicts.


The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

Correspondence to Prashanthan Sanders, MBBS, PhD, Centre for Heart Rhythm Disorders, Department of Cardiology, Royal Adelaide Hospital, Adelaide, 5000, Australia. E-mail

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Is Endurance Exercise Safe in AFib?

While there are gaps in the evidence related to epidemiology and mechanisms of atrial fibrillation (AFib), these patients should be encouraged to be physically active with moderation, according to a state-of-the-art review published online Aug. 30 in JACC: Clinical Electrophysiology.

N. A. Mark Estes III, MD, FACC, and Christopher Madias, MD, examined whether exercise is detrimental to patients with AFib and found a considerable body of evidence supporting an increased incidence of AFib in high-intensity endurance athletes. The frequency of AFib is estimated to be between two and 10 times greater in high-intensity endurance athletes than in sedentary individuals, but much of this evidence is retrospective and observational. Much of the data have been largely focused on men, and recent evidence suggests there might be a sex-specific effect.

While there are multiple knowledge gaps regarding pathophysiologic mechanisms underlying the development of AFib in athletes, proposed mechanisms include alterations of autonomic tone, left atrial enlargement and fibrosis, electrical remodeling and increased inflammation. Studies have shown that at rest and during low intensity physical activity, endurance athletes have dominant vagal tone compared with non-athletes. Additionally, mechanical as well as electrophysiologic remodeling have been noted in endurance athletes.

It is common to recommend that athletes with symptomatic AFib reduce the duration and intensity of exercise for up to three months to assess the relationship between exercise and AFib. If this results in a meaningful decrease in AFib, it is reasonable to allow resumption of less intense exercise and reassess the symptoms related to AFib. However, if an athlete chooses not to reduce their exercise, it is reasonable for physicians to respect the athlete’s decision and advance alternate therapeutic approaches for the AFib. Recommendations regarding continued sports participation for the competitive athlete have been recently updated and can guide clinicians in advising athletes with AFib. Of note, athletes with AFib that is well tolerated and self-terminating may participate in competitive sports without the need for any therapy.

“Clinicians must use the limited, but best available data to manage these patients,” the authors write. “To the extent that the cardiovascular benefits of exercise are well established, all patients should be encouraged to be physically active with moderation. The evidence is conclusive that sedentary lifestyles contribute to AFib development independent of gender. Physical activity in moderation decreases the risk of AFib in men and women; however, men should be advised of the potentially increased risk of AF with long term, high-intensity endurance training.”

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Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Prevention, Sports and Exercise Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Exercise

Keywords: Athletes, Atrial Remodeling, Sedentary Lifestyle, Incidence, Atrial Fibrillation, Retrospective Studies, Physical Endurance, Sports, Exercise, Rest, Inflammation, Electrophysiology

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Exercising with Atrial Fibrillation

Exercise is key to living with AFib

Atrial fibrillation shouldn’t stop you from pursuing a healthy, active lifestyle. In fact, atrial fibrillation patients can reap many benefits by pursuing an exercise program. Exercise can reduce the frequency and severity of AFib episodes in addition to lowering blood pressure and slowing your resting heart rate.

Of course, none of this means you should launch yourself into running a marathon after years of sedentary living. You need to be careful as you design your exercise program.

Before you exercise, know what type of AFib you have

There are four types of AFib: persistent, paroxysmal, vagal, and adrenergic. Knowing which one you have effects how you should approach your exercise routine.

1. Persistent AFib patients are nearly always in AFib. Since it’s usually best to exercise when one is not suffering from an episode these patients will need to be especially careful to stick to gentle, low-impact programs.

2. Paroxysmal AFib patients have episodes that come and go. Within reason, they can pursue just about any program they like, if they don’t overdo it.

3. Vagal AFib is when your episodes occur mostly during or after a meal or resting after exercise. This type of atrial fibrillation is related to the vagus nerve. For some people with this type of AFib, exercise can actually help stop the episodes.

4. Adrenergic AFib is when your episodes occur mostly during the day and are normally triggered by exercise, exertion, or stimulants. In this type of AFib the adrenaline hormone is the trigger. For some people with this type of AFib, exercise can trigger an episode.

How to choose the right exercise program for you

It’s important to start by focusing on light-to-moderate programs like brisk walking, Tai Chi, or yoga. Make sure you don’t get above 50% to 70% of your maximum heart rate. Calculate this by subtracting your age from the number 220. If you’re 40 years old your maximum heart rate is 180 and you don’t want to get above 126 bpm.

If you’re on beta blockers you might have to use the Borg RPE scale as an alternative, since beta blockers exist to keep your heart rate low. The Borg scale is a measure of “perceived exertion.” The CDC offers a lot of information about it, but here’s the bottom line: you should aim to keep your perceived exertion somewhere between 11 and 14 on a 1-20 scale while you work out.

Avoid weight lifting because it can put a great deal of strain on your heart. Strength training is important, but resistance band training is safer and more effective for AFib patients.

Tips for a more successful exercise experience

Be vigilant about taking care of yourself during your exercise time. This means setting realistic goals, staying hydrated, and watching for signs you may be overdoing it such as dizziness. If you’ve been sedentary for a long time, start out slow. Pay attention to weather conditions: the last thing you want to do is overheat.

Think about personal safety, too. If you’re on blood thinners, for example, a major exercising accident could be very dangerous. Wear protective gear and take precautions to ensure you can get help if you have an injury that makes you bleed.

Beware of overdoing your exercise

Pushing too hard is the number one reason why exercise may become unsafe for someone with atrial fibrillation. Don’t rely on monitoring methods or Borg scales alone. If you can’t speak a full sentence without gasping for air, then you are overdoing it. Lightheadedness, excessive sweating, and chest pains are other danger signs.

You might feel like you’re “accomplishing more” when you start to push harder, but remember: even if you don’t trigger an episode your body will hit a wall. If you start associating exercise with pain and discomfort you won’t want to do it, and the least effective exercise is the one you never get around to doing at all.

Keep exercise fun so you’ll want to do it…and don’t let AFib stop you from getting out there and getting active.

Author by line:
Travis Van Slooten is an atrial fibrillation patient who has been passionate about providing knowledge, inspiration, and support to fellow afibbers through his blog at www.livingwithatrialfibrillation.com


Exercising with Atrial Fibrillation

Having heart-related issues like atrial fibrillation may make you feel concerned about whether it’s safe for you to exercise, even if you’ve been regularly involved in consistent physical activity for years. You may be concerned that raising your heart rate by exercising could actually worsen your AFib. Recent studies indicate that some people living with AFib do better with exercise. In most cases and for most people, moderate exercise is beneficial for both your heart and your AFib symptoms, although there are some individuals who find that exercise seems to trigger symptoms of AFib. A recent small study on AFib and exercise found that people with Afib who engaged in regular exercise reported fewer problems with AFib symptoms and said their quality of life improved. They were able to better manage their everyday activities than those with AFib who didn’t exercise. Physical activity can also help lower blood pressure, reduce blood sugar, and improve energy and sleep. So whether you’re just starting or you’re a trained athlete, if your doctor has said exercise is okay for you, feel free to get up and move each day. Learn more about how you can get the most out of your physical activity:

Can I or should I exercise If I have AFib?

Always ask your healthcare provider to be sure. Before starting any exercise routine, check with your healthcare provider or cardiologist to find out what is reasonable and safe for you, given your specific physical condition and capabilities.

What do I need to know about exercise and AFib?

Learn important facts about AFib and exercise.

Getting Started With Exercise While Managing AFib

We all want the benefits of regular physical activity. So what can you do if you’re just getting started or you’d like to increase your motivation?

Weight loss and exercise may ease atrial fibrillation

Research we’re watching

Published: May, 2018

For people with atrial fibrillation, losing a little weight and getting exercise may improve their symptoms, according to a review published online Feb. 7, 2018, by The American Journal of Cardiology.

Atrial fibrillation (or afib) is a common heart rhythm disorder marked by a quivering or fluttering heartbeat, which can cause dizziness and breathlessness. Other symptoms include fatigue, weakness, and fainting.

Researchers identified 10 studies that examined lifestyle strategies to manage afib. The strongest evidence came from three studies on weight loss and four on exercise. The weight-loss interventions featured low-calorie diets and moderate exercise, which were linked to fewer and shorter bouts of afib. The improvements were more pronounced among people who lost at least 10% of their weight.

The exercise studies included different interventions, ranging from brisk walking to running for various times and frequencies. Over all, getting regular moderate to vigorous exercise was associated with improved quality of life and fewer symptoms in people with afib. Both weight loss and exercise may complement other therapies to treat afib, including medications and procedures, the authors concluded.

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Atrial Fibrillation in Competitive Athletes

Atrial fibrillation (AF) is characterized by irregular atrial activity that replaces normal sinus rhythm leading to loss of the regular atrial contraction during left ventricular diastolic filling.1 This condition increases the risk of thromboembolic events, heart failure and mortality.2 Among athletes, AF impairs cardiac efficiency, affecting exercise capacity and athletic performance. Here we describe a case of AF in an athlete and provide a brief overview of the condition and features specific for this highly active population.

Case 1

41-year-old male, former US National Team rower and experienced marathon runner, presented with palpitations during rest and AF with a ventricular rate of 140bpm on Holter monitoring. During sinus rhythm his resting heart rate was 53. He had no significant past medical history but reported a family history of premature coronary artery disease. He denied taking performance enhancing supplements or caffeinated beverages. He endorsed consuming two glasses of wine per week without binge drinking. Lab investigations revealed no electrolyte or thyroid abnormalities. Echocardiogram revealed normal left atrial size (LAVI 23ml/m2), normal LV dimension (LVIDd 5.2cm), normal LV thickness (posterior wall 1.0cm, septum 0.9cm) and normal ejection fraction. His coronary calcium score was 0. As the patient was not planning to compete in the near future, he opted to reduce his level of recreational exercise. Three months after a moderate exercise ‘dose’, his symptoms entirely subsided and repeat Holter monitoring revealed no further atrial fibrillation.

The Association Between Exercise and AF

Several case control studies over the past two decades have revealed the complex relationship between endurance exercise and risk of developing AF. At low to moderate levels of exercise, there is a lower risk of AF.3,4 However, rather than a linear benefit derived from increasing levels of exercise, there appears to be a threshold beyond which increasing exposure is associated with an increased risk of AF.5-12 The most compelling evidence for a dose- and intensity- dependent association between endurance exercise and AF comes from a long distance competitive skiing event, Vasaloppet, in Sweden.12 In >50,000 skiers, the strongest predictors of AF were the number of races completed and race times. A meta-analysis including six case-control studies corroborated these findings with a five-fold increase in the risk of developing AF among older endurance athletes than non-athletes.13

Whether gender-specific differences occur as it relates to risk of AF and long-term endurance exercise is controversial and represents an active area of investigation.14 Unfortunately, it is difficult to derive meaningful conclusions in female athletes as the vast majority of existing literature pertains to male athletes, and sub-group analyses are often underpowered. Indeed, a number of studies have failed to demonstrate any increased risk of AF in female athletes.15-17 A meta-analysis including 103,298 highly active female participants (mean age ranged from 54 to 63 years) assessed the risk of AF among women who regularly undertake intense exercise.17 The pooled odds ratio was 0.72 (95% CI 0.57–0.88, P < 0.001), indicating that intense exercise was associated with a 28% lower risk of AF. However, in the studies included for analysis, ‘intense’ exercise was defined as either ≥4 hours of exercise per week, heavy physical workload, endurance exercise 3 times per week or activities requiring ≥6 METs‐hours/week. Therefore, high-level endurance athletes who truly live in the upper end of the exercise dose-response curve were not well represented in this analysis.17

Etiology of AF in Athletes

Although causality cannot be established from these studies, mechanistic pathways likely involve exposure to triggers in the setting of an arrhythmogenic substrate and modulators as outlined in Figure 1.

Atrial dilatation may act as an arrhythmogenic substrate, although the relationship between left atrial size and AF in athletes is more complex than in sedentary individuals.18 Atrial fibrosis may also enhance AF in athletes, as has been shown in mice exercise models.19 Modulating factors could include an increase in vagal tone, which itself increases the risk of AF as well as intrinsic conduction changes genetically mediated by ion channel remodeling.20-22 It is also possible that environmental and lifestyle triggers act as the ‘final hit’ in a dual or multi-hit hypothesis for AF in athletes. Stimulants, alcohol and performance enhancing drugs are all pro-arrhythmogenic, while viral illness and psychosocial stressors may be other salient triggers for AF in athletes.

Figure 1: Mechanisms That May Increase the Risk of AF in Athletes

Clinical Approach to Athletes With AF

Many athletes, unlike their non-athletic counterparts, experience symptoms related to AF. In vagal mediated AF, episodes may interrupt sleep at nighttime and may occur post-exercise, particularly if using alternating heat/cold recovery therapy. A detailed history is warranted with particular emphasis on triggering factors and the relationship of exercise with AF, as well as traditional risk factors such as alcohol intake. Specific to athletic individuals, it is important to enquire about use of stimulants, anabolic steroids and other performance enhancing drugs. Some reports also suggest that exercise induced esophageal reflux may be important in AF and as such should be appropriately explored.23


While AF is typically recorded by a 12-lead electrocardiogram (ECG), modern wearable devices are increasingly becoming a tool used for AF detection. As such, it is important to obtain the initial recording documenting the athlete in AF. Subsequent investigations include a resting 12-lead ECG as well as prolonged remote monitoring. Other methods of ECG monitoring include ‘patch’ devices, smartphone enabled rhythm recorders and smartwatches, which may sometimes be more appropriate for athletes compared to traditional Holter monitors. Blood pressure measurement is crucial to rule out the presence of hypertension. Laboratory investigations are important to elucidate whether electrolyte abnormalities, often related to exercise and dehydration or underlying thyroid disease, may act as inciting reversible factors. Exercise testing defines the maximal heart rate and may unmask exercise induced symptoms and arrhythmias.

Management of AF in Athletes

Due to the paucity of data investigating athletes with AF, many of the current recommendations are based upon expert consensus and extrapolation from evidence in non-athletes. Similar to non-athletes, the mainstay of management is prevention of symptoms with a rhythm or rate control strategy, protection from thromboembolic risk and modification of risk factors. However, there are three unique challenges when faced with an athlete with AF. First, the chosen therapy should control AF without impairing exercise performance. Second, this therapy must comply with the list of prohibited substances by the athlete’s respective sporting body. Third, consideration of the optimal anti-coagulation strategy must include assessment of the training-related bleeding risk.

Role of Detraining

If the risk of atrial fibrillation increases with increasing exercise levels, it is plausible that a reduction in exercise training will reduce the incidence of recurrent AF. Preliminary data from endurance trained animal models support this theory.24 The position paper from the European Society of Cardiology recommend a total detraining period of up to two months for restoration and maintenance of sinus rhythm. However, this is rarely well received by the athlete and may be unacceptable at the elite level.25 By contrast, the American Heart Association and American College of Cardiology recommend athletes with well tolerated, self-terminating low-risk AF may participate in all competitive sports without therapy (Class I; Level of Evidence C).26

Rate or Rhythm Control?

In our practice, we prefer a rhythm control strategy as athletes are often symptomatic in AF despite adequate rate control. Additionally, rate control is often limited by physiologic resting sinus bradycardia. We prefer a Class IC antiarrhythmic strategy such as flecainide as a ‘pill-in-the-pocket’ approach. Class IC anti-arrhythmic agents reduce the risk of AF recurrence more so than beta-blockers and have a better safety profile than class IA drugs in non-athletes.27 Ideally the first dose is taken under direct observation in the hospital in order to mitigate against the risk of adverse events, which occurs in roughly 5%.28 Although not well explored in athletes, disopyramide (Class IA), through its anticholinergic effect, may provide benefit in vagal mediated AF in athletes. However, until further studies demonstrate its benefit in this cohort, we remain cautious in its use due to an association with a small increase in mortality for paroxysmal AF.27

Pulmonary vein isolation by means of radiofrequency catheter ablation is an established treatment for AF in non-athletes and may be a useful option for athletes with recurrent AF refractory to medical treatment or intolerant of medical therapies. In a 3-year follow-up of 94 predominantly male athletes with paroxysmal AF, Koopman et al. showed a similar rate of AF recurrence between athletes and controls.29 In this study, non-endurance athletes required more ablations than endurance athletes within the three year period.29 For athletes who undergo an ablation procedure, they can typically return to play after 2-12 weeks.30 We direct the reader to the following references that provide an overview in support and against catheter ablation for AF in athletes, respectively.31,32

Thromboembolic Risk

Similar to non-athletes, thromboembolic risk is paramount in the management of AF in athletes, regardless of whether a rate- or rhythm control strategy is preferred. The CHA2DS2-VASc risk stratification scheme reliably identifies ‘lone’ AF patients who are at truly low risk of thromboembolic events.33 Therefore, athletes who score zero can be adequately reassured without necessitating anti-coagulation. In those that warrant anticoagulation, it is important to weight the benefit of anticoagulation against the bleeding risk related to training. When conventional risk factors are present in athletes who continue to train, an attempt should be made to reverse or modify these rather than view them as an indefinite reason for anticoagulation. Although not well documented in athletes, left atrial appendage occlusion may be useful in those unable to take anticoagulation therapy.


AF in athletes has been well documented and is likely mediated by processes distinct to AF observed in the general older population. In the case presented in this review, his prior high-level exposure to endurance exercise may have led to the development of AF. Athletes present unique challenges that require an open dialogue of the evidence behind different treatment strategies and shared decision making to provide the optimal therapy for a given athlete. We welcome further research in this field to better inform our guidelines and allow us to provide more superior cardiovascular care for the athletic heart.

  1. Iwasaki YK, Nishida K, Kato T, Nattel S. Atrial fibrillation pathophysiology: implications for management. Circulation 2011;124:2264-74.
  2. Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the long-term risks associated with atrial fibrillation: a 20-year follow-up of the Renfrew/Paisley study. Am J Med 2002;113:359-64.
  3. Pathank RK, Elliott A, Middeldorp ME, et al. Impact of CARDIOrespiratory FITness on arrhythmia recurrence in obese individuals with atrial fibrillation: the CARDIO-FIT study. J Am Coll Cardiol 2015;66:985-96.
  4. Mozaffarian D, Furberg CD, Psaty BM, Siscovick D. Physical activity and incidence of atrial fibrillation in older adults: the cardiovascular health study. Circulation 2008;118:800-7.
  5. Baldesberger S, Bauersfeld U, Candinas R, et al. Sinus node disease and arrhythmias in the long-term follow-up of former professional cyclists. Eur Heart J 2008;29:71-8.
  6. Karjalainen J, Kujala UM, Kaprio J, Sarna S, Viitasalo M. Lone atrial fibrillation in vigorously exercising middle aged men: case-control study. BMJ 1998;316:1784-5.
  7. Elosua R, Arguer A, Mont L, et al. Sport practice and the risk of lone atrial fibrillation: a case-control study. Int J Cardiol 2006;108:332-7.
  8. Claessen G, Colyn E, La Gerche A, et al. Long-term endurance sport is a risk factor for development of lone atrial flutter. Heart 2011;97:918-22.
  9. 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 2010;17:100-5.
  10. Molina L, Mont L, Marrugat J, et al. Long-term endurance sport practice increases the incidence of lone atrial fibrillation in men: a follow-up study. Europace 2008;10:618-23.
  11. Aizer A, Gaziano JM, Cook NR, Manson JE, Buring JE, Albert CM. Relation of vigorous exercise to risk of atrial fibrillation. Am J Cardiol 2009;103:1572-7.
  12. Andersen K, Farahmand B, Ahlom A, et al. Risk of arrhythmias in 52,755 long-distance cross-country skiers: a cohort study. Eur Heart J 2013;34:3624-31.
  13. Abdulla J, Nielsen JR. Is the risk of atrial fibrillation higher in athletes than in the general population? A systematic review and meta-analysis. Europace 2009;11:1156-9.
  14. Morseth B, Graff-Iversen S, Jacobsen BK, et al. Physical activity, resting heart rate, and atrial fibrillation: the Tromso Study. Eur Heart J 2016;37:2307-13.
  15. Wilhelm M, Roten L, Tanner H, Wilhelm I, Schmid JP, Saner H. Gender differences of atrial and ventricular remodeling and autonomic tone in nonelite athletes. Am J Cardiol 2011;108:1489-95.
  16. Everett BM, Conen D, Buring JE, Moorthy MV, Lee IM, Albert CM. Physical activity and the risk of incident atrial fibrillation in women. Circ Cardiovasc Qual Outcomes 2011;4:321-7.
  17. Mohanty S, Mohanty P, Tamaki M, et al. Differential association of exercise intensity with risk of atrial fibrillation in men and women: evidence from a meta-analysis. J Cardiovasc Electrophysiol 2016;27:1021-9.
  18. Pelliccia A, Maron BJ, Di Paolo FM, et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 2005;46:690-6.
  19. Aschar-Sobbi R, Izaddoustdar F, Korogyi AS, et al. Increased atrial arrhythmia susceptibility induced by intense endurance exercise in mice requires TNFα. Nat Commun 2015;6:6018.
  20. Carpenter A, Frontera A, Bond R, Duncan E, Thomas G. Vagal atrial fibrillation: what is it and should we treat it? Int J Cardiol 2015;201:415-21.
  21. Stein R, Medeiros CM, Rosito GA, Zimerman LI, Ribeiro JP. Intrinsic sinus and atrioventricular node electrophysiologic adaptations in endurance athletes. J Am Coll Cardiol 2002;39:1033-8.
  22. D’Souza A, Bucchi A, Johnsen AB, et al. Exercise training reduces resting heart rate via downregulation of the funny channel HCN4. Nat Commun 2014;5:3775.
  23. Swanson DR. Running, esophageal acid reflux, and atrial fibrillation: a chain of events linked by evidence from separate medical literatures. Med Hypotheses 2008;71:178-85.
  24. Guasch E, Benito B, Qi X, et al. Atrial fibrillation promotion by endurance exercise: demonstration and mechanistic exploration in an animal model. J Am Coll Cardiol 2013;62:68-77.
  25. Heidbuchel H, Panhuyzen-Goedkoop N, Corrado, et al. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions part i: supraventricular arrhythmias and pacemakers. Eur J Cardiovasc Prev Rehabil 2006;13:475-84.
  26. Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes NAM 3rd. 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 2015;66:2412-23.
  27. 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.
  28. Alboni P, Botto GL, Boriani G, et al. Intravenous administration of flecainide or propafenone in patients with recent-onset atrial fibrillation does not predict adverse effects during ‘pill-in-the-pocket’ treatment. Heart 2010;96:546-9.
  29. Koopman P, Nuyens D, Garweg C, et al. Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation. Europace 2011;13:1386-93.
  30. Raju H, Kalman JM. Management of atrial fibrillation in the athlete. Heart Lung Circ 2018;27:1086-92.
  31. McNamara D, Link M. Ablation of atrial fibrillation in athletes: PRO. http://www.acc.org. Mar 8, 2017. Accessed Nov 16, 2018. https://www.acc.org/latest-in-cardiology/articles/2017/03/08/10/06/ablation-of-af-in-athletes-pro.
  32. Madamanchi C, Chung E. Ablation of atrial fibrillation in athletes: CON. http://www.acc.org. Mar 8, 2017. Accessed Nov 16, 2018. https://www.acc.org/latest-in-cardiology/articles/2017/03/08/10/06/ablation-of-af-in-athletes-con.
  33. Potpara TS, Polovina MM, Licinia MM, Marinkovic JM, Prostran MS, Lip GY. Reliable identification of “truly low” thromboembolic risk in patients initially diagnosed with “lone” atrial fibrillation: the Belgrade atrial fibrillation study. Circ Arrhythm Electrophysiol 2012;5:319-26.

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Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension

Keywords: Sports, Athletes, Atrial Fibrillation, Performance-Enhancing Substances, Electrocardiography, Ambulatory, Risk Factors, Heart Rate, Coronary Artery Disease, Stroke Volume, Dilatation, Heart Atria, Athletic Performance, Heart Failure, Testosterone Congeners, Life Style, Case-Control Studies, Pulmonary Veins, Anti-Arrhythmia Agents, Dehydration, Atrial Appendage, Blood Pressure, Bradycardia, Catheter Ablation, Electrocardiography, Hypertension, Gastroesophageal Reflux, Cholinergic Antagonists, Thyroid Diseases, Cohort Studies

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6 Exercises That Are Safe to Do When You’re Living With A-Fib

In a study published in February 2017 in the Cochrane Database of Systematic Reviews, researchers concluded that based on six trials involving exercise-based cardiac rehab for people with A-fib, the programs appeared to improve exercise capacity. (7)

2. Walking Even though walking might seem like a very low-risk activity, “typically, we ask patients up front, at least, not to do any brisk walking,” says Hussein.

If you’re just starting out, Hussein recommends walking 5 to 10 minutes daily at first, then adding a minute or two to your walks every week or so.

3. Swimming Swimming and other pool-based aerobic exercises can be a good way to work out “but not at a competitive level, from an A-fib-risk standpoint,” says Hussein.

And if you find yourself out of breath or feel like you’re otherwise struggling, it’s important to get out of the pool and sit down for a while. (2)

4. Bicycling Using a stationary or regular bicycle can be a good form of activity, but make sure to keep the intensity moderate. Stay away from settings that encourage heavy exertion, such as a Spin class.

5. Physical chores Physical activity doesn’t have to mean doing exercise separately from your daily tasks. In addition to walking to go on errands, you can count gardening, digging, raking, or hoeing as exercise, as long as it gets your heart rate up. (8)

6. Yoga In a study published in the Journal of the American College of Cardiology, a 60-minute yoga program done twice a week for three months was found to reduce A-fib episodes and symptoms, reduce depression and anxiety, and improve heart rate and blood pressure in people with atrial fibrillation. (9)

Remember that no matter what activity you’re doing, if you experience any symptoms related to A-fib — like lightheadedness or chest pain or pressure — you should stop and rest for a while, says Hussein.

And if you have more serious symptoms like passing out or intense chest pain, visit a hospital emergency room.

In most cases, though, you should be able to accomplish moderate exercise without any risk of causing or aggravating your symptoms.

“Aerobic activity is good,” says Hussein, but “don’t push your limits.”

8 Easy Exercises You Can Do with Afib

  • 1

    Atrial fibrillation affects at least 3 million people in the U.S., according to the American Heart Association, making it one of the most common kinds of heart arrhythmia.

    But don’t let it deter you from exercising. You can definitely benefit from physical activity, as long as the activity you choose doesn’t generate an uncontrolled heart rhythm. Just consult your doctor and develop an exercise plan together that will suit your specific needs. Talk to your physician and try these Afib-safe exercises.

    8 Easy Exercises You Can Do with Afib https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F8d%2F59%2F318c9a9a4dc193d647b3977f3a66%2Fresizes%2F1500%2Fimage-couple-standing-in-the-sun.jpg

  • 2

    One of the best things about walking is the versatility that it offers. You can—and should—start with a short walk and then gradually build up to longer walks. You can also start slow and speed up when you’re ready. You can walk outdoors in your neighborhood or indoors at the mall or around a track. Be sure to wear comfortable, sturdy shoes.

    Walking https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1494×999%2B5%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F74%2F33%2Fc49b0c9a470eaaa41eb5df3b642c%2Fresizes%2F1500%2Fgettyimages-183870858-rf-hg.jpg

  • 3

    One of the great advantages of riding a bike is getting some aerobic exercise that’s good for your heart without also putting extra strain on your joints. Hop on a stationary bike at the gym, or take a spin around the neighborhood on a regular bike—and remember to wear that helmet. As with any activity, start slow and don’t push yourself too hard.

    Biking https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F7b%2Fac%2Ff1a1101040dcba04f5107ece3930%2Fhumira-SS-exercise-7.jpg

  • 4

    Swimming is another great low-impact, easy-on-the-joints activity that you can tailor to your own pace and ability. Grab a kickboard and paddle yourself through a few laps. Ask about lap-swim times at your neighborhood community or senior center, if you want some company or some inspiration from fellow swimmers.

    Swimming https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F7f%2F1a%2Fde5a36ba4b2cace6d872dc78bb93%2Fpool.jpg

  • 5

    Building your muscles will give you more endurance and help you navigate the tasks of daily living more easily. It will also help build bone density and reduce your risk of falling. You’ll want to rotate through exercises that work all your major muscle groups. Concentrate on good form and quality reps–not the amount of weight. Most of all, be careful. The Centers for Disease Control and Prevention (CDC) recommends that you start slowly and work to gradually increase your level of activity. The American College of Sports Medicine suggests working up to three strength-training sessions per week.

    Strength Training https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F38%2F13%2Fed7247634dc2b3af1af60ae46c6f%2Fresizes%2F1500%2Fimage-senior-man-weight-lifting.jpg

  • 6

    It doesn’t count toward the 150 minutes of moderately intense exercise that the CDC recommends for most adults, but yoga offers many other benefits. Work on your balance and flexibility by practicing a series of poses. You’ll soon discover the positive impact it makes on all your other exercise activities. Yoga can also help you de-stress and feel calmer. The American Heart Association suggests that yoga can help lower your blood pressure and boost circulation too.

    Yoga https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F2c%2F74%2F650e9ff64111877cca3bf4eee40f%2Ftaming-rosacea-triggers-4.jpg

  • 7

    Pick your favorite way to make your mark on the dance floor: ballroom dancing, salsa dancing, line dancing, maybe a little Zumba. Make sure you don’t overexert yourself while you’re groovin’ on the dance floor, though. If you’re self-conscious about dancing in front of others but want to try it anyway, get started by having your own personal dance party in the privacy of your own living room while following a DVD, televised workouts, or even YouTube exercise videos.

    Dancing https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F02%2F19%2Fb28360bd44628d83384e06495dfc%2Fresizes%2F1500%2Fimage-senior-couple-dancing.jpg

  • 8

    Cardiologists often advise patients who need a cardiac devise like a pacemaker to avoid contact sports, which makes golf a good option. Leave the driving to the driving range, however, and opt for walking instead of riding in the cart. That way, you’ll get in some walking, which is great low-impact, cardiovascular exercise.

    Golf https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fea%2F51%2F8a1f0a06418087dd6a9cc1028778%2Fresizes%2F1500%2Fimage-getty-154957321.jpg

  • 9

    Grab your racquet and head out to the court with a pal to play a friendly match. Try to schedule your matches for days when the temperature and humidity are relatively mild, though, or book a time at an indoor court. And if you experience an uneven heart rhythm while you’re on the court, take a break and sit down to rest for a while.

    Tennis https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F7b%2F02%2F189150904c53b69a48a30f5c110f%2Fresizes%2F1500%2Fimage-tennis-lesson.jpg

  • 10

    If you are feeling light-headed or woozy, it’s time to stop. If you feel extremely fatigued or notice that you’re feeling some chest pain, call your physician immediately.

    Know when to stop. https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F8f%2Fee%2Fa2349a3f4a238085e022c1dca6c6%2Fresizes%2F1500%2Fimage-senior-man-drinking-from-water-bottle.jpg

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