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Running head: ATRIAL FIBRILLATION IN ATHLETES 1 Atrial Fibrillation in Athletes Tammie Brueckner, PAS-2 Nova Southeastern University College of Health Care Sciences Physician Assistant Department-Jacksonville Master of Medical Science PAJ 6370: Clinical Elective Rotation 1, Cardiology Professor Bolton Elective “Clinical Brief” Due February 2, 2015 ATRIAL FIBRILLATION IN ATHLETES 2 Atrial Fibrillation in Athletes Introduction Atrial fibrillation (AF) is the most common sustained supraventricular tachyarrhythmia, and a clear direct association with age exists especially after the seventh decade of life (Andreoli, Benjamin, Griggs, & Wing, 2010). The presence of AF is detectible by some patients who may complain of palpitations, shortness of breath, fatigue, reduced exercise capacity or dizziness, and a thorough cardiac evaluation should be performed to determine an underlying or precipitating cause (Cheng & Kumar, 2014). In the general population typical risk factors for AF include hypertension and coronary heart disease, but it is important to remember that AF is caused by a change in the electrophysiology of the atrial myocardium; in athletes, recent evidence suggests that increased parasympathetic tone, reduced sympathetic tone and increased inflammation puts this subset of the population at risk for AF (Sorokin, Araujo, Zweibel, & Thompson, 2011). Atrial Fibrillation Epidemiology. Atrial fibrillation affects approximately 9% of individuals over 80 years of age and often appears paroxysmally over a period of time before it becomes the established rhythm (Papadakis & McPhee, 2014). In adults less than 55 years old, the prevalence drops to less than 0.1% and appears to be more common in Caucasian men (Cheng & Kumar, 2014). The incidence of AF also increases with advancing age and with underlying cardiovascular diseases. According to the Framingham study, men ages 40 to 95 have a 26% risk of developing AF, and a 23% risk from ages 80 to 95, which illustrates how AF incidence arises with age (Cheng & Kumar, 2014). Pathogenesis and Diagnosis. Atrial tachycardia (AT) occurs at rates between 100-250 beats per minute due to an ectopic focus that is firing at a rate faster than the sinus rate (Andreoli ATRIAL FIBRILLATION IN ATHLETES et al., 2010). Atrial flutter (AFl) occurs with a reentry impulse in the right atrium, which passively activates the left atrium. According to Moe’s hypothesis, atrial fibrillation is maintained by having a critical number of wavelets circulating the atria and result in ineffective atrial contraction. Many times during AF, impulses are blocked at the atrioventricular (AV) node resulting in an irregular ventricular rhythm taking over. An electrocardiogram for AT and AFl will show unique P-wave morphologies, while AF will show no distinct P-wave activity (Andreoli et al., 2010). A thorough history and physical can elucidate the presence of active AF, but with intermittent episodes the application of a Holter Monitor or even a continuous loop recorder can aid in the diagnosis (Cheng & Kumar, 2014). Sometimes AF can be found incidentally in healthy patients who have a CHADS2 score of zero, meaning that they have no comorbidities and a low risk of ischemic stroke; this type of AF where there is an absence of structural heart disease is termed lone AF (Cheng & Kumar, 2014; Li, Zhang, Scherlag, & Po, 2010). Treatment. The American Heart Association (AHA) sets guidelines for diagnosing and treating AF with the goal of lowering the risk of consequences such as stroke or myocardial infarction. Treatment options vary with each patient and are outside the scope of this article. Exercise The AHA (2015) suggests at least 150 minutes per week of moderate activity or 75 minutes per week of vigorous activity, or thirty minutes a day, or a combination of both. Adults who follow this regimen are less likely die of heart disease and stroke, which are the nation’s number 1 and number 5 causes of death. To lower blood pressure or cholesterol, AHA recommends 40 minutes of aerobic exercise like walking, jogging swimming or biking. 3 ATRIAL FIBRILLATION IN ATHLETES 4 Athletes. Competitors often train at levels much more intense and for periods much greater than recommended by the AHA, and with constant strain the heart goes through stages of remodeling (Li et al., 2010). It is important for athletes to pay attention to any symptoms that may indicate the presence of AF, discussed previously in this article. Discussion It is widely accepted that regular aerobic exercise reduces cardiovascular risk (Li et al., 2010). Many health care providers harp on the importance of exercise and diet, but many patients hear this without listening. While exercise seems to be avoided at all costs by much of the population, other people take it to the extreme. Athletes push their bodies to limits, and with the help of medicine, supplements and determination, they overcome obstacles to reach their goals. There are many side effects of too much exercise, from injuries to death, but one thing that most athletes and their healthcare providers often overlook is their susceptibility to atrial fibrillation. There appears to be a consensus that no exercise and high intensity exercise may lead to AF, and recommendations lean toward low to moderate intensity exercise to reduce the incidence of AF (Li et al., 2010). Taking age into account, elderly people can reduce their risk of AF by participating in moderate physical activities; however if their cumulative lifetime hours are longer than 1500, the incidence of AF increased (Li et al., 2010). Marathon runners who practiced more than 3 hours weekly for more than 2 years also had a higher incidence of AF (Li et al., 2010). Even more interesting is a study that showed mortality is much lower in a group of elite athletes than their sedentary control group, but the incidence of AF was much higher (Sorokin et al., 2009). The relationship between the cardiac autonomic nervous system and AF suggests that atrial stretch in a dilated atrium can induce AF by providing a place for reentry of the impulse ATRIAL FIBRILLATION IN ATHLETES 5 (Po et al., 2010). Another study showed excessive exercise raised the C-reactive protein level, which is also elevated in AF patients (Sorokin et al., 2009). Conclusion While exercise can be used to improve overall cardiovascular health, excess activity may actually lead to AF (Sorokin et al.,). Due to changes in the electrophysiology of the atrial myocardium, which can be produced through strenuous and long term exercise, AF can occur during an athlete’s prime or later in life at a higher incidence than people who exercise at moderate levels (Po et al.,). ATRIAL FIBRILLATION IN ATHLETES 6 References American Heart Assocation recommendations for physical activity in adults, 2015. (http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/Ame rican-Heart-Association-Recommendations-for-Physical-Activity-inAdults_UCM_307976_Article.jsp) Andreoli, T., Benjamin, I., Griggs, R., Wing, E. (Ed.). (2010). Andreoli and Carpenter's CECIL Essentials of Medicine (8 ed.). Philadelphia PA: Saunders Elsevier. Cheng, A., Kumar, K. (2014). Overview of Atrial Fibrillation. In G.M. Saperia (Ed.), UpToDate. Retrieved from http://www.uptodate.com/home Li, S., Zhang, Z., Scherlag, B., & Po, S. (2010). Atrial fibrillation in athletes - the story behind the running hearts. Journal of Atrial Fibrillation, 1(11), 626-629. Papadakis, M., McPhee, S. (Ed.). (2014). Current Medical Diagnosis & Treatment (53rd ed.). New York NY: McGraw Hill. Sakabi, K., Fukuda, N., Soeki, T., Shinohara, H., Tamura, Y., & Wakatsuki, T. (2003). Relation of age and sex to atrial electrophysical properties in patients with no history of atrial fibrillation. Cardiology and Clinical Research, 26(3), 1238-1244. Sorokin, A. V., Araujo, C. G., Zweibel, S., & Thompson, P. D. (2011). Atrial fibrillation in endurance-trained athletes. British Journal of Sports Medicine, 45(3), 185-188. American Heart Assocation recommendations for physical activity in adults (http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/FitnessBasics/Ame rican-Heart-Association-Recommendations-for-Physical-Activity-inAdults_UCM_307976_Article.jsp)