What is Atrial fibrillation (AF)?

Atrial Fibrillation (AF) is a common heart rhythm disorder that affects a significant portion of the population, particularly those in middle to older age, and happens when abnormal electrical impulses suddenly start firing in the atria. These impulses override the heart's natural pacemaker, which can no longer control the rhythm of the heart. This causes you to have a highly irregular pulse rate.

This usually occurs in the smaller chambers of the heart, the atria, it is more common than the Ventricular Tachycardia (VT) which may require a defibrillator.
However, there is a higher risk of stroke with Atrial Fibrillation.

Endurance exercise and Atrial Fibrillation

According to Associate Professor La Gerche, numerous studies highlight a higher incidence of Atrial Fibrillation among endurance athletes, but only those with a long history of training at a high level. Research, including a study on retired Olympic rowers, suggests a sevenfold increase in Atrial fibrillation among endurance athletes compared to the general population.  

The incidence of AF in individuals engaging in regular physical activity at a moderate level is far less than that in sedentary people, demonstrating once again the benefit of regular exercise.

https://www.germanjournalsportsmedicine.com/archive/archive-2020/issue-10/endurance-exercise-and-atrial-fibrillation-a-state-of-the-art-review

Other endurance sports also include long-distance running, cycling, cross-country skiing, and triathlon, exhibit a higher prevalence of Atrial Fibrillation. The intensity and prolonged duration of exertion contribute to its occurrence.

Genetic Factors

While there is a genetic predisposition to Atrial Fibrillation, the risk is not significantly greater in athletes than in the general population. The interplay between genetics and exercise complicates the understanding of Atrial Atrial Fibrillation.

Atrial Fibrillation: symptoms and presentation

The journey with Atrial Fibrillation often begins when individuals experience palpitations or a racing heart. The most common symptom is palpitations, characterised by a faster-than-expected heart rate.

The feeling of irregularity, such as the heartbeat not being regular, is another key symptom. Some individuals may also experience a pounding sensation. Dr David Bertovic comments that, athletes might not exhibit these symptoms but could observe a significant decrease in exercise 

For example, you may be riding the same route that you have completed over many years in the same conditions, and for some reason you find it increasingly challenging to maintain the same pace/speed, though nothing else has changed in your overall health.

Devices like the Apple Watch can aid in the diagnosis, and monitoring heart rate variations is crucial according to Associate Professor Andre La Gerche.

Distinguishing from other conditions

Atrial Fibrillation, while not causing sudden death, can be confused with other rhythm problems associated with serious cardiac issues. Awareness of symptoms like racing and irregular heartbeats is crucial according to  Associate Professor La Gerche.

Are women equally at risk

Recent evidence suggests that Atrial Fibrillation is also common in women, though the risk might be less than in men. Women generally exhibit more electrically stable hearts, resulting in fewer arrhythmias.
 

Initial consultation with a Healthcare Professional

When individuals first present with symptoms suggestive of Atrial Fibrillation, the initial step is usually a consultation with a healthcare professional, often a General Practitioner (GP).

Palpitations and changes in exercise capacity are key discussion points. The healthcare provider will inquire about the nature of the symptoms, asking whether the heart rate is fast, irregular, pounding, or a combination of these. For athletes, a decrease in exercise capacity may be the primary indicator.

When to consult a Cardiologist

The decision to consult a cardiologist is one to discuss with your GP. If symptoms persist or worsen, and a diagnosis of Atrial Fibrillation is confirmed, the patient and healthcare team must consider the next steps.

Athletes, accustomed to pushing their limits, may need to assess their exercise routines and discuss potential modifications with their healthcare provider.

Diagnostic process: from ECG to monitoring

Diagnosing Atrial Fibrillationsleep can be challenging, as some individuals may not exhibit classical symptoms. The condition might be incidentally discovered during routine medical examinations or procedures, such as a colonoscopy.

The diagnostic process often involves an Electrocardiogram (ECG), which may be repeated over time to capture episodes. Recently, advancements in technology, such as smartwatches and portable ECG devices, provide individuals with the ability to record their heart rhythm during symptomatic episodes, enhancing diagnostic yield.

Lifestyle factors, exercise intensity and risk

Understanding the factors that may trigger or contribute to Atrial Fibrillation is crucial. Lifestyle factors, including sleep apnea, uncontrolled high blood pressure, thyroid issues, and alcohol consumption, can play a role.

Athletes, especially those engaged in endurance exercise, may need to evaluate their training intensity and duration. Balancing the benefits of exercise with potential risks becomes pivotal in managing Atrial Fibrillation according to Dr David Bertovic.

The relationship between exercise intensity and Atrial Fibrillation risk is complex. While there's no specific threshold, studies explore how different exercise patterns may contribute to atrial fibrillation according to Associate Professor Andre La Gerche

Tailoring Treatment to the Individual

The management of Atrial Fibrillation involves a combination of conservative, medical, and procedural approaches. Conservative measures include identifying and managing precipitants, such as addressing sleep apnea or controlling high blood pressure.

Medical therapy may involve medications to control heart rate or rhythm, and anticoagulants to reduce the risk of stroke. Procedural interventions, such as ablation procedures, are considered in cases where conservative and medical treatments have not been successful.

Additionally, athletes may need to strike a balance between maintaining their exercise routines and managing the condition effectively.

Ablation Procedures: A surgical option

Ablation procedures, particularly pulmonary vein isolation can be effective, but these procedures are invasive and come with potential risks and complications.

The decision to pursue ablation should be carefully discussed between the patient and their healthcare team, weighing the potential benefits against risks according to Professor La Gerche.

Awareness and advocacy

A crucial aspect of managing Atrial Fibrillation is patient awareness and advocacy. Individuals experiencing symptoms should not hesitate to seek medical advice and collaborate with healthcare providers to find the most suitable treatment plan.

Athletes, in particular, need to be attuned to changes in exercise capacity and communicate openly with their healthcare team.

So do we stop exercising?

Atrial Fibrillation poses unique challenges, especially for individuals who are physically active. By understanding the symptoms, diagnostic process, and available treatment options, patients and healthcare professionals can work together to manage Atrial Fibrillation effectively.

Awareness, open communication, and a tailored approach contribute to improved outcomes and quality of life for individuals living with Atrial Fibrillation according to Dr Bertovic.

Assoc Professor La Gerche states that even though Atrial fibrillation is more common in endurance trained athletes, there's a lot of health benefits associated with endurance exercise and these outweigh the risks.
 

It's not the end of the world

This article initially came about when having that chat in the bunch with Wayne Hyett, one of the stalwarts  of Melbourne's famous North Ride ride.

When initially confronted with the diagnosis, Wayne's initial expectations were a straightforward solution to what was perceived as minor heart issues. However, as medical tests, including ultrasounds, revealed the severity of the problem in real-time, the situation became more complex. The specialist painted a clear picture of the seriousness of the issue using visual aids, being deeply confronting and leaving Wayne feeling vulnerable for the first time in his life and about his own mortality.

Pride, medication and acceptance

Reflecting on his lifetime commitment to health and fitness, eating well with regular exercise and never needing medication until now, the prospect of medication-induced limitations on performance and lifestyle was a significant adjustment. 

For Wayne, leading our regular 5:45 am ride was a benchmark, and now the realisation that certain physical activities might be restricted due to the diagnosis led to a sense of mourning for the perceived loss of strength and capabilities. Over time, acceptance became a crucial aspect of adapting to the new reality, leading to a process of coming to terms with the limitations imposed by the condition and medication.

Though ultimately, this doesn't take away from his enjoyment of riding, especially with his regular riding mates.

 

The information presented in this article is for informational purposes only and should not be considered as medical advice. It is not intended to be relied upon nor replace consultation with a qualified healthcare professional.

References

www.researchgate.net/figure/U-shaped-relationship-between-the-exercise-dose-and-the-relative-risk-of-developing_fig2_251878923
 

Andre La Gerche
Associate Professor
St Vincent's Hospital Melbourne
 

Dr David Bertovic

MBBS, BMed Sci (Hons), FRACP
Cardiologist

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