CASE REPORT
SPORT AND ATRIAL FIBRILLATION
1Mansour M Al Nozha FRCP; 2Yasir H. Sharif MRCP
King Fahad Cardiac Center, King Khalid University Hospital,
Riyadh, Saudi Arabia
Physical exercise is prescribed
for the prevention of coronary artery disease,
obesity and type II diabetes mellitus. Those who
perform regular physical exercise are usually
considered as healthy people most of the time.
However, atrial fibrillation (AF) can occur in
otherwise healthy middle-aged men engaged in long
term vigorous sports with no clear underlying
etiology. We describe a young man who developed
atrial fibrillation during swimming.
A 29-year-old male who was not known
to A have any medical problem before, was admitted
to our hospital with a history of palpitation
for one day. His symptoms started while he was
swimming. After seven laps of swimming, he experienced
palpitation, which was continuous and associated
with dizziness for a short time. In the past,
he had a similar episode of palpitation which
occurred while performing exercise. He was started
on propranolol 10mg twice daily after being seen
in a private clinic but he stopped treatment two
months prior to his current admission.
He was an ex-smoker and had no past history of
medical or surgical illness. He described himself
as active, athletic, and swam regularly. He had
no history of anabolic steroids use and denied
history of alcohol intake.
On physical examination, he was not in distress,
weight was 59 kg and height was 158 cms. Vital
signs revealed a BP of 115/70 with no postural
drop, and heart rate was 82/m, irregularly irregular.
Hissystemicexaminationrevealedno abnormalities.Chestx-raywasnormal.
Laboratory investigations such as CBC, urea and
electrolytes, thyroid function test and liver
function tests were normal. ECG showed AF with
a ventricularresponseof82/min.An echocardiogram
revealed normal left ventricular dimension (LVEDD
= 48 mm, LVEDS = 28 mm), good left ventricular
systolic function, a left atrial size of 30 mm,
ejection fraction of 60%, no regional
wallmotionabnormalities,trivialmitral
regurgitation and trivial tricuspid regurgitation.
The patient was admitted to the hospital with
a diagnosis of atrial fibrillation and he was
started on bisoprolol 5 mg daily and connected
to telemetry. Two days post-admission he reverted
spontaneously to sinus rhythm.His condition remained
stable and he was discharged home on bisoprolol,
5 mg daily.
He was seen in the clinic two months post discharge.
Clinically, he was asymptomatic, and he was found
to have regular pulse and a normal ECG.
Atrial fibrillation (AF) is a common
arrhythmia and a significant public health problem.
It occurs in 0.4 % -2.0 % of the general population.
The prevalence of AF increases with advancing
age and in the elderly, the prevalence is above
5%. Atrial fibrillation is becoming more prevalent
with time, even after adjustment for age and structural
heart diseases1-5. In the USA, the prevalence
of atrial fibrillation in the general population
increased with time from 0.4% in the year 1965
to 0.8% in the year 1997, and it is estimated
that there are 2.2 million Americans with AF.
While patients can be asymptomatic, many patients
experience a wide variety of symptoms including
palpitations, dyspnea, dizziness, fatigue, angina
and congestive heart failure. In addition, thearrhythmiacanbeassociatedwith
haemodynamic dysfunction, tachycardia-induced
cardiomyopathy and systemic embolism.Data from
Framingham heart study show that AF is associated
with 1.5- to1.9-fold higher risk of death, which
may be due to thromboembolic stroke6. AF is responsible
for more admissions to hospitals than any other
dysarrhythmia. Approximately 85% of patients who
present with AF are subsequently found to have
an underlying cardiac or metabolic disorder. In
the other 15% no definitive diagnosis or discrete
abnormality is ever found7. In younger adults
however, it has been estimated that over 90% of
AF is paroxysmal. The true frequency of paroxysmal
AF (PAF) is unknown8.
AF is usually associated with hypertension, ischemic,
rheumatic or cardiomyopathic heart disease. In
comparison with our patient's data, there was
no evidence of an underlying etiology for AF and
his echo did not reveal any abnormalities suggestive
of an underlying ischemia or cardiomyopathy.
PAF does occur in thyrotoxic patients and it is
usually associated with rapid ventricular response.
From the history, clinical examination, and investigation,
there was no indication of thyroid disease in
this case. Non-medical use of anabolic steroids
by athletes has been shown to be associated with
cardiovascular diseases. Self-administration of
large amount of androgens (anabolic steroids)
has been associated with grossly hypertrophied
hearts at autopsy, generalized and focal fibrosis,
significant myofibrillar disarray as well as hypertrophy
of interventricular septum and left ventricular
wall 9.
Sullivan et al.9 reported a case of a young male
body builder who consumed large doses of anabolic
steroids (AS) and who presented to the emergency
department with symptomatic atrial fibrillation.
Echocardiography revealed significant septal hypokinesia,
and the posterior wall thickness was at the upper
limit of normal for highly trained athletes.
The
atrial fibrillation had not recurred at ten weeks
after discontinuation of anabolic steroid use.
Consumption of these agents in athletes has been
associated with hypertension, hypertrophic cardiomyopathy
and sudden cardiac death. Our patient had no history
of anabolic steroid intake.
The relation between exercise and atrial fibrillation
was studied in 1160 patients seen at the arrhythmia
outpatient clinic in the Institute of Cardiovascular
Disease, Spain: 6% of the patients were found
to have lone atrial fibrillation and were younger
than 65 years; 32 of them had been engaged in
long term sports practice and their episodes of
atrial fibrillation started at a younger age;
they had a lower incidence of mild hypertension
and their episodes of atrial fibrillation were
predominantly vagal in contrast to sedentary patients.
The echocardiographic parameters were similar
to those observed in the sedentary patients, but
when compared with 20 healthy controls, they showed
greater atrial and ventricular dimensions and
higher ventricular mass. The investigators concluded
that long-term vigorous exercise may predispose
to atrial fibrillation10.
Athletes are subjected to the same arrhythmias
induced by exercise as the general population,
but the frequency and significance of the arrhythmias
may be different.
Cardiovascular conditioning
slows the heart rate and may make the athletes
more vulnerable to neurocardiogenic syncope and
atrial fibrillation. Tachyarrhythmias may be precipitated
by vigorous exercise and more severe rate-related
symptoms may result because of the high sympathetic
drive during sport activities11.
The ECG variants and cardiac arrhythmias in athletes
showed that supraventricular and AV node ectopic
beats are not more frequent in athletes than in
the general population except for atrial fibrillation12.
Mazzone et al published an article about atrial
fibrillation in elite athletes. They analyzed
the presence of AF, paroxysmal or chronic, in
a population of young elite athletes, including
previous Olympic and world champions, who were
studied for arrhythmias that endangered their
athletic careers. They studied 1,464 males and
308 females (mean age 21 years) from 1974-1977;
further follow up was available in 146 athletic
(122 males and 24 females; mean age 24 years)
from 1985-1997. They found that most of those
athletes who developed AF were males and the episode
of AF occurred during effort. They concluded that
AF, occurring in young elite athletes and affecting
only males, is one of the most frequent causes
of prolonged palpitations and can be reproduced
easily by transesopahgeal atrial pacing or electrophysiological
testing13. Atrial fibrillation may be a cause
of disqualification from sports eligibility, but
may disappear if the athletic activity is stopped
for an adequate period of time.
Chronic sports practice may contribute
to development of atrial fibrillation in male
patients. Although only few studies have considered
a possible relationship between sports activity
and atrial fibrillation, these studies have shown
that the proportion of sportsmen with lone AF
is much higher than that reported in the general
population.
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11. Mc-Govern-BA; Liberthson R.
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