Essential guidelines for managing atrial fibrillation in athletes

The diagnosis and management of atrial fibrillation in athletes present unique challenges.

Atrial fibrillation (AF) is an irregular and often rapid heart rhythm. It happens when the upper chambers of the heart (the atria) beat out of sync with the lower chambers (the ventricles). This can cause a fast, fluttering or pounding heartbeat, and sometimes it leads to symptoms like shortness of breath, fatigue or chest pain. If left untreated, AF can increase the risk of stroke and heart disease.

Clinical guideline parameters for the diagnosis and management of AF are presented below, with an emphasis on what matters for athletes.

Clinical guidelines for atrial fibrillation

Internationally, there are well-established clinical guidelines for AF in the general population. These guidelines serve as a framework for clinicians to provide evidence-based care for patients with AF, aiming to improve outcomes, reduce symptoms, and prevent complications such as stroke. It is important to refer to the full guidelines for detailed recommendations and specific clinical scenarios. Prominent examples of guidelines are:

The ACC/AHA/HRS 2019 Focused Update of the 2014 Atrial Fibrillation Guideline, which emphasises the importance of a comprehensive initial evaluation, individualised rate and rhythm control strategies, and appropriate anticoagulation based on stroke risk assessment; and

The 2020 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Management of Atrial Fibrillation, which provides similar recommendations with a focus on a holistic approach, including lifestyle modifications and patient-centred care.

Athlete focus: 

Guidelines for managing AF in athletes are scant.The needs of athletes have only recently become addressed in international clinical guidelines, including the 2020 European Society of Cardiology (ESC) Guidelines on Atrial Fibrillation (pp. 71–72) and the 2024 Heart Rhythm Society (HRS) Expert Consensus Statement on Arrhythmias in the Athlete. The 2018 Australian guidelines, while comprehensive, do not provide specific recommendations for managing AF in athletes.

In the absence of randomised controlled trials, recommendations for AF management in athletes are based largely on evidence in non-athletes, observational data and expert consensus.

Early detection and diagnosis

Routine screening for AF is recommended in high-risk populations, utilising electrocardiograms (ECGs) for accurate diagnosis.

Athlete focus:

In the first instance, it is crucial to differentiate between symptoms of overtraining and those indicative of AF. Athletes may experience AF-related symptoms such as palpitations, fatigue and shortness of breath, which can impact performance and quality of life.

Risk stratification

Stroke risk should be assessed using tools like the CHA2DS2-VASc score. This is like a checklist where different risk factors, such as age, high blood pressure, diabetes and previous strokes, are given points. The higher the total score, the greater the risk of having a stroke. This helps doctors decide whether a patient should take blood thinners (anticoagulants) to lower their risk.

Athlete focus:

Risk stratification for athletes with atrial fibrillation involves the above “standard” approach, including a comprehensive assessment of clinical, functional, and structural factors to help tailor management plans that balance the benefits of continued physical activity with the potential risks associated with AF (note, these factors are also usually assessed in the general population). Key components of risk stratification for athletes include:

Resting ECG:  Documenting the presence of AF and any other cardiac abnormalities 

Holter Monitor:  Assessing the frequency and severity of AF episodes and detect any associated arrhythmias 

Echocardiogram:  Evaluating cardiac structure and function, including left atrial size, left ventricular function, and the presence of any structural heart disease 

Exercise Stress Test: Assessing the heart’s response to physical exertion, including the development of arrhythmias and ischaemic changes during exercise

Management approach

The management of atrial fibrillation (AF) in the general population involves a comprehensive approach that aims to control symptoms, prevent complications, and address underlying causes.

Athlete focus:

Treatment for athletes may involve a combination of medication, lifestyle modifications and, potentially, adjustments to their training regimen. Athletes with AF are often desperate to know how treatments will affect performance, whether they can return to competition, and when. Relatively young and otherwise healthy athletes are generally poorly tolerant of medical management options and can be averse to long-term anti-arrhythmic drug therapy.

Regular monitoring and collaboration with sports cardiologists can help optimise treatment plans. The following points emphasise the importance of designing a treatment approach for AF that takes into account an athlete’s previous experience and accommodates their intentions (e.g., to potentially resume their sport within a competitive framework) while moving forwards with a diagnosis of AF.

Medical management

The cornerstones of AF medical management are anticoagulation and rate and/or rhythm control. Several factors are considered when determining whether to use a rhythm-control or rate-control strategy. Most clinicians focus initially on the restoration and maintenance of the normal heart rhythm (sinus rhythm) in patients with new-onset AF and opt for a rate-control strategy only when rhythm control fails or when patients are symptomatically limited by AF.

Anticoagulation medications:

Anticoagulants (often called blood thinners) are recommended for patients with a high risk of stroke. In AF, the heart’s irregular beat can cause blood to pool in the heart chambers and form clots which can travel to the brain and cause a stroke. Anticoagulants help to keep the blood flowing smoothly and reduce the risk of dangerous clots forming. The main problem with anticoagulants is that they can cause bleeding with potentially serious outcomes. Treatment plans must be individualised, based on a patient’s risk profiles and preferences.

Athlete focus:

The need for anticoagulation in athletes is determined by clinical risk factors, consistent with guidelines for the general population.

Sports with direct bodily contact or prone to trauma should be avoided in patients on oral anticoagulation therapy.

Evidence suggests that athletes with resolved AF may still be at an increased risk of stroke and could benefit from continued anticoagulant prophylaxis, similar to non-athletes. Yet, this necessitates finding a balance between recommended anticoagulant therapy and potential bleeding risks inherent to sports participation

Rate control medications:

Rate control medications for atrial fibrillation are used to slow down the heart rate to a normal level, even though the heart rhythm may still be irregular. These medications help manage symptoms like palpitations and shortness of breath and reduce the risk of heart failure. Here are the main types of rate control medications:

Beta-blockers:  These drugs, such as metoprolol, atenolol and propranolol, reduce the heart rate by blocking the effects of adrenaline on the heart.

Calcium channel blockers:  Medications like diltiazem and verapamil help slow the heart rate by blocking calcium from entering the heart muscle cells and so relax the heart and blood vessels.

Digoxin:  This medication helps control the heart rate by increasing the strength of heart contractions and slowing the electrical signals in the heart. Used primarily in patients with heart failure or sedentary lifestyles.

Athlete focus:

Medical therapy for AF (which slows the heart rate) is frequently contraindicated or poorly tolerated. This is because athletes have a high prevalence of sinus bradycardia (i.e., a slower-than-normal heart rate, which is often observed in well-trained athletes whose hearts are very efficient and don’t need to beat as quickly) and sinus pauses (i.e., a brief hiccup in the heart’s rhythm, where it stops for a second and then goes back to beating normally).

Digoxin and verapamil (a calcium channel blocker) are less effective for controlling heart rate during exertion. They act by mechanisms that are more effective at rest and less effective during physical exercise.

Rhythm control medications:

Rhythm control strategies for atrial fibrillation aim to restore and maintain a normal heart rhythm (also known as sinus rhythm). These strategies can help reduce symptoms, improve quality of life, and prevent complications. The main antiarrhythmic drugs are:

Flecainide: Helps to maintain a normal heart rhythm by blocking sodium channels in the heart.

Propafenone: Works similarly to flecainide by affecting the electrical activity of the heart.

Amiodarone: A powerful medication that can help restore and maintain normal heart rhythm; however, its long-term use has potential side effects.

Sotalol: Combines beta-blocker and antiarrhythmic properties to help control heart rhythm.

Athlete focus:

Pill-in-the-pocket therapy is a treatment option for those who have infrequent episodes of symptomatic AF. With this approach, athletes can take a single dose of an anti-arrhythmic drug when they feel palpitations to help convert the irregular rhythm back to a normal, regular heart rhythm.

After ingestion of antiarrhythmic drugs such as flecainide or propafenone, however, it is recommended that sports activity is avoided until the AF ceases and two half-lives of the drug have elapsed.

Minimally invasive procedures

AF catheter ablation is a medical procedure that aims to restore normal heart rhythm by destroying (ablating) the small areas of heart tissue that are causing the abnormal electrical signals which lead to resultant abnormally fast heartbeats.  Catheter ablation (CA) has become an established invasive procedure in patients with atrial fibrillation (AF) refractory to anti-arrhythmic drugs. 

Athlete focus:

AF catheter ablation is often preferred by athletes. It has been similarly efficacious in both the athletic and non-athletic populations in small studies.

Lifestyle modifications

Lifestyle changes are encouraged, such as weight management and regular exercise, including addressing modifiable risk factors like hypertension, diabetes and sleep apnoea. Reducing alcohol and caffeine intake, and managing stress, can also help control heart rhythm.

Athlete focus:

Detraining considerations – In some cases, reducing the intensity or frequency of endurance exercise (detraining) may lower the risk of AF and its complications. However, this approach should be balanced with the athlete's goals and preferences.

Conclusion

The management of atrial fibrillation in athletes requires a nuanced approach that considers their unique risks and demands. While Australian and international guidelines provide a robust framework for AF management, further research and specific guidelines tailored to athletes are needed. Clinicians should emphasise early detection, risk stratification and personalised treatment strategies, ensuring that athletes receive optimal care while maintaining their performance and health.

The evolving understanding of AF in athletes highlights the importance of ongoing research and guideline updates to address this complex issue effectively.

---

References

European Society of Cardiology (20 Aug 2020). 2020 guidelines for management of atrial fibrillation: ESC clinical practice guidelines. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Atrial-Fibrillation-Management

Hindricks G et al. (2020). 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). European Heart Journal, 00: 1–125. https://www.escardio.org/static-file/Escardio/Guidelines/Documents/ehaa612.pdf

Hindricks G, et al. (2021). 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. https://pubmed.ncbi.nlm.nih.gov/32860505/

Eur Heart J. (2021 Feb 1); 42(5):373-498. doi: 10.1093/eurheartj/ehaa612.

Erratum in: Eur Heart J. (2021 Feb 1); 42(5):507. doi: 10.1093/eurheartj/ehaa798.

Erratum in: Eur Heart J. (2021 Feb 1);4 2(5):546-547. doi: 10.1093/eurheartj/ehaa945.

Erratum in: Eur Heart J. (2021 Oct 21); 42(40):4194. doi: 10.1093/eurheartj/ehab648. PMID: 32860505.

Lampert et al. (17 May 2024). 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm (Practice Guidelines), Article in press: https://www.heartrhythmjournal.com/article/S1547-5271(24)02560-8/fulltext

McCallum CJ, Raja DC, Pathak RK. (2019). Atrial fibrillation: an update on management. Australian Prescriber, 42:186–91. https://doi.org/10.18773/austprescr.2019.067

Rosenthal L et al. (18 Nov 2019). Atrial fibrillation treatment and management. Medscape: theheart.org https://emedicine.medscape.com/article/151066-treatment?form=fpf

Umerah Co, Momodu II (updated 2023 Jul 17). Anticoagulation. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK560651/