Research ArticlePractice

Atrial fibrillation and physical activity

Should we exercise caution?

N. John Bosomworth
Canadian Family Physician December 2015; 61 (12) 1061-1070;

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Cardiovascular Health Study data to determine hazard ratios for AF, by exercise levels: Circled data point indicates a statistically significant change from baseline.

    AF–atrial fibrillation.

    Data from Mozaffarian et al.35

  • Figure 2
    Figure 2

    Physicians’ Health Study data to determine hazard ratios for AF, by PA per week: Circled data point indicates a statistically significant change from baseline.

    AF–atrial fibrillation, PA–physical activity.

    Data from Aizer et al.36

  • Figure 3
    Figure 3

    National Walkers’ and Runners’ Health studies data to determine hazard ratios for arrhythmias: Circled data points indicate a statistically significant change from baseline.

    Data from Williams and Franklin.41

  • Figure 4
    Figure 4

    Hazard ratios for AF of competitive skiers, by number of completed races: Circled data points indicate a statistically significant change from baseline.

    AF–atrial fibrillation.

    Data from Andersen et al.39

  • Figure 5
    Figure 5

    Characteristics of endurance exercise speculated to promote AF

    AF—atrial fibrillation.

Tables

  • Table 1

    Cohort studies

    STUDYSTUDY CHARACTERISTICSMEAN AGE OF PARTICIPANTS, YDEFINITION OF HIGH-INTENSITY EXERCISE AND END POINTSOUTCOMESLIMITATIONSRISK OF BIAS
    Karjalainen et al,31 1998• Top-level veteran orienteers (ie, runners)
    • 228 in orienteer group vs 212 in control group; 100% men
    • 10-y follow-up    		47.5• High position in veteran ranking is an indicator of y of intense training
    • Lone AF    		• AF developed in 5.3% of orienteers vs 8.9% of control group (RR = 5.5; P = .012)• Men only
    • Cohort information insuffcient
    • No correction for confounding
    • Unreliable outcome assessment
    • Potential recall bias    		High
    Frost et al,32 2005• Danish Diet, Cancer, and Health Study data
    • 19–593 (51%) men and 18 807 women
    • Mean 5.7-y follow-up    		56• Heavy physical workload (self-report)
    • AF or atrial futter    		• No differences between the sexes*
    • No differences overall*    		• Few subjects exposed to heavy work or vigorous PA
    • Relied on registry outcomes
    • Could not separate AF from atrial futter
    • Potential recall bias    		Moderate
    Heidbuchel et al,33 2006• 137 patients after ablation for atrial futter; 83% men
    • 31 of the 137 patients regularly engaged in sports before ablation
    • Mean 2.5-y follow-up    		58• Intense competitive activity ≥ 3 h per wk
    • Development of AF after ablation for atrial futter    		• AF development in high PA (HR = 1.81; P = .02)
    • No differences between the sexes    		• Status after ablation not comparable
    • Higher rate of cardiovascular disease
    • Potential for recall bias
    • No correction for confounding    		Moderate
    Molina et al,34 2008• 252 Barcelona marathon runners vs 305 sedentary men; 100% men
    • Retrospective cohort study
    • Mean 11.6-y follow-up    		39• Marathon running
    • Lone AF    		• Endurance sport practice associated with higher risk of lone AF (HR = 8.80, 95% CI 1.26 to 61.29; P = .028)*• Men only
    • Control group recruited from different population
    • 5-y difference in follow-up duration
    • Risk of recall bias
    • All AF events not considered    		Moderate
    Mozaffarian et al,35 2008• Cardiovascular Health Study Medicare eligibility lists in US communities
    • 5446 participants; 42% men
    • Post hoc analysis of RCT
    • 12-y follow-up    		73• ≥6 MET† of intensity
    • ≥ 1840 kcal/wk (self-report)
    • AF on annual examination or electrocardiogram    		• Graded reduction in AF with light to moderate PA intensity*
    • No reduction in AF with high PA intensity
    (RR = 0.87, 95% CI 0.64 to 1.19)*• With an older cohort, there was less high-intensity PA
    • No sex differences examined    		Low
    Aizer et al,36 2009• 16–921 men in Physicians’ Health Study
    • Post hoc analysis of RCT
    • 12-y follow-up    		51• Suffcient to “work up a sweat” 5–7 d/ wk (self-report)
    • AF    		• RR for 0 vs 5–7 d/wk (joggers) of vigorous exercise was 1.20 (95% CI 1.02 to 1.41; P = .04)*
    • Elevated risk observed if aged < 50 y (RR = 1.74, 95% CI 1.23 to 2.47;
    P < .01)    		• Men only
    • Some retrospective subgroup analysis
    • Association seen at 3-y evaluation but not at 9 y    		Low
    Pelliccia et al,37 2010• 114 Olympic athletes vs 97 people in control group; 78% n
    • 8.6-y follow-up    		22• Participation in Olympic-endurance disciplines and having multiple games experience
    • Cardiac symptoms or events    		• No cardiac events developed for more than 8 y
    • Reduced incidence compared with general population    		• Very young study cohort
    • Small group and therefore few potential outcomes
    • Screening of multiple cardiovascular systems before enrolment
    • Control group was very ft; had participated in 1 Olympic game    		High
    Everett et al,38 2011• 34 759 women who had been part of the Women’s Health Study
    • 20-y follow-up    		57.5• ≥ 6 MET† of intensity
    • ≥ 15 MET† h/wk
    • AF    		• No difference in incident of AF among quintiles after adjusting for hypertension and obesity*• Women only
    • Very few women underwent strenuous activity
    • Self-assessment of PA intensity
    • Self-assessment of outcomes    		Low
    Andersen et al,39 2013• 52 755 Swedish participants in a 90-km cross-country skiing event; 87% men
    • Mean 9.7-y follow-up    		38.5• Fast finishing time or high number of races completed
    • AF or atrial flutter    		• Higher risk of AF among those who completed > 5 races (HR = 1.29, 95% CI 1.04 to 1.61) and among those who had the fastest relative fnishing times (HR = 1.20, 95% CI 0.93 to 1.55)*• Outcomes include AF or atrial futter
    • Cohort was still extremely active and not representative of general population    		Low
    Thelle et al,40 2013• 309 540 Norwegians in a public health screening program; 48% men
    • 4-y follow-up    		41.4• Frequent hard training or competitive PA
    • Flecainide prescription    		• Increase in AF in men with high intensity PA (HR = 3.14, 95% CI 2.17 to 4.54)*• High attrition rate over time
    • Surrogate outcome (fecainide) for lone AF
    • Self-assessment of PA intensity
    • Risk of recall bias    		Moderate
    Williams and Franklin,41 2013• 46 807 participants in the National Runners’ and Walkers’ Health studies; 41% men
    • Age range was 33–72 y
    • 6.2-y follow-up    		NA• ≥ 6 MET† of intensity
    • ≥ 5.4 MET† h/d
    • Any cardiac arrhythmia    		• Arrhythmia risk declined by 4.8% each MET† h/d over baseline for runners and walkers*
    • Beneft was higher for those aged < 50 y    		• Self-report of PA intensity
    • Self-report of physician diagnosis
    • No differentiation of arrhythmia type
    • Risk of selection bias
    • Incomplete statistical reporting    		Moderate
    Bapat et al,42 2014• Participants from MESA databaseNA• Highest of 3 PA intensity categories was > 2383 MET† min/wk
    • AF    		• At highest intensity PA in 1 model, HR = 0.79, 95% CI 0.61 to 1.02; P < .05*• There are insuffcient data to properly evaluate this studyHigh
    Drca et al,43 2014• 44 410 Swedish men
    • Mean follow-up of 12 y    		60• Any leisure-time PA of > 5 h/wk
    • AF or atrial futter    		• Walking or cycling at age 30 y showed beneft in AF reduction
    • Risk of AF increased at age 30 y for > 5 h/wk of PA (RR = 1.19, 95% CI 1.05 to 1.36; P = .008)*    		• Men only
    • Risk of recall bias
    • Self-assessment of PA intensity
    • Outcomes included AF and atrial futter    		Moderate
    Ghorbani et al,44 2014• 28 169 US men
    • 8-y follow-up    		68• PA > 6 MET† with high MET h/wk• No correlation between AF and PA*• Men only
    • Self-assessment of PA intensity
    • Self-report of physician diagnosis
    • Participation and dropout rates were unclear    		Moderate
    Knuiman et al,45 2014• 4267 adults from Busselton, Western Australia; 44% men
    • 15-y follow-up    		52• Vigorous exercise in a usual week
    • AF    		• Higher level of PA associated with non-signifcant trend to reduced AF*• 57% survey response
    • Self-assessment of PA intensity
    • Risk of recall bias    		Moderate
    Myrstad et al,46 2014• 2366 Norwegian men participating in 56-km cross-country ski race vs 1179 men from general population
    • 9-y follow-up    		66• Endurance PA for > 30 min > 3 times per wk
    • AF or atrial futter    		• Increased risk of AF for 10 y of vigorous PA (HR = 1.16, 95% CI 0.06 to 1.28) in skiers*• Men only
    • Controls from different population
    • Self report of recent PA
    • Risk of selection bias    		Moderate

    • AF—atrial fibrillation, HR—hazard ratio, MESA—Multi-Ethnic Study of Atherosclerosis, MET—metabolic equivalent task, NA—not available, PA—physical activity, RCT—randomized controlled trial, RR—relative risk.

    • ↵* After adjustment for confounding variables.

    • ↵† A physiologic measure of energy cost of a physical activity: 1 MET = 1 kcal/kg/h.

  • Table 2

    Studies in athletes

    STUDYSTUDY TYPETYPE OF ATHLETESAF OUTCOMESRISK OF BIAS
    Andersen et al,39 2013CohortSwedish cross-country skiers for 90-km event• HR = 1.29 (95% CI 1.04 to 1.61) for > 5 completed races
    • HR = 1.20 (95% CI 0.93 to 1.55) for those with fastest times
    • 87% of study participants were men    		Low
    Baldesberger et al,47 2008Case controlFormer Swiss elite cyclists• AF developed in 10% of cyclist group and in 0% of control group (BGD P value of .028)
    • Study included only men    		High
    Grimsmo et al,48 2010Cross sectionalElite-level Norwegian cross-country skiers• AF prevalence of 16.7% was found
    • Lone AF prevalence of 12.8% was found
    • Study included only men    		High
    Karjalainen et al,31 1998CohortTop-level orienteers (runners)• AF developed in 5.3% of orienteers vs 8.9% of control group (RR = 5.5; P = .012)
    • Study included only men    		High
    Molina et al,34 2008Retrospective cohortRunners in Barcelona Marathon• Endurance sport practice associated with higher risk of lone AF (HR = 8.80, 95% CI 1.26 to 61.29; P = .028)
    • Study included only men    		Moderate
    Myrstad et al,46 2014CohortNorwegian crosscountry ski racers for 56-km event• Increased risk of AF for 10 y of vigorous PA (HR = 1.16, 95% CI 0.06 to 1.28)
    • Study included only men    		Moderate
    Myrstad et al,49 2014Cross sectionalParticipants in Birkebiner crosscountry ski race—a course of 54 km and 1000 m uphill• AF in men currently practising endurance sport (OR = 1.81, 95% CI 1.04 to 3.14)
    • Study included only men
    • 78% of study participants were men    		High
    Pelliccia et al,37 2010CohortOlympic athletes• No cardiac events developed for more than 8 y
    • Reduced incidence compared with general population    		High
    Van Buuren et al,50 2012Cross sectionalElite German handball players• AF prevalence of 30.3% in former athletes
    • Study included men only    		High

    • AF—atrial fibrillation, BGD—between-group difference, HR—hazard ratio, OR—odds ratio, PA—physical activity, RR—risk ratio.

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Atrial fibrillation and physical activity
N. John Bosomworth
Canadian Family Physician Dec 2015, 61 (12) 1061-1070;
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