Ageing, Comorbidities, and the Complex Determinants of Atrial Fibrillation in Athletes

Eduard Guasch; Stanley Nattel


Eur Heart J. 2021;42(35):3526-3528. 

In This Article

Abstract and Introduction


Graphical Abstract: Impact of age in the relationship between exercise and atrial fibrillation risk in men. The risk of atrial fibrillation associated with exercise varies according to age (upper left); the effects of very high-intensity exercise in aged individuals are uncertain. Atrial senescence, risk factor burden and physical performance contribute to different impacts of exercise at different ages (right). These factors modulate the balance of potential pro- and anti-arrhythmogenic mechanisms (bottom). This is a schematic with approximate regular exercise load estimations based on the literature.[2,4,5]


Regular physical activity is one of the most powerful therapies to fight illness, including cardiovascular disease.[1] However, like any other largely beneficial intervention, too much exercise can be counterproductive and the consequences of excess physical activity have often been overlooked.

Emerging evidence suggests that moderate training and intense endurance exercise have different consequences for cardiovascular remodelling.[1] Coronary calcification burden is increased in master athletes, but the causes and potential consequences are incompletely understood.[1] In addition, the myocardium can be remodelled by intense exercise. An association between vigorous exercise training and an increased risk of atrial fibrillation (AF) has been recognized for over 20 years. The data are compelling for highly trained endurance athletes.[1] Lifelong strenuous endurance training associates with an up to five- to eight-fold increased risk of AF vs. non-athletes,[1] depending on factors like the amount and intensity of training. Results in the general population are conflicting, however. Recent large studies[2] and meta-analyses suggest a consistent reduction in AF with all levels of exercise in women, but a shift from protection to increased risk at high levels of exercise in men.[3] Are meta-analyses missing a part of the puzzle and oversimplifying the complex foundations of AF in athletes? What factors other than the exercise dose need to be considered? In this Viewpoint article, we consider how ageing influences AF risk in trained individuals and the impact for clinical practice.