Prevalence and Clinical Significance of Left Atrial Remodeling in Competitive Athletes
Open accessAbstract
Objectives In the present study we assessed the distribution and clinical significance of left atrial (LA) size in the context of athlete's heart and the differential diagnosis from structural heart disease, as well as the proclivity to supraventricular arrhythmias. Background The prevalence, clinical significance, and long-term arrhythmic consequences of LA enlargement in competitive athletes are unresolved. Methods We assessed LA dimension and the prevalence of supraventricular tachyarrhythmias in 1,777 competitive athletes (71% of whom were males), free of structural cardiovascular disease, that were participating in 38 different sports. Results The LA dimension was 23 to 50 mm (mean, 37 +/- 4 mm) in men and 20 to 46 mm (mean, 32 +/- 4 mm) in women and was enlarged (i.e., transverse dimension > or = 40 mm) in 347 athletes (20%), including 38 (2%) with marked dilation (> or = 45 mm). Of the 1,777 athletes, only 14 (0.8%) had documented, symptomatic episodes of either paroxysmal atrial fibrillation (n = 5; 0.3%) or supraventricular tachycardia (n = 9; 0.5%), which together occurred in a similar proportion in athletes with (0.9%) or without (0.8%; p = NS) LA enlargement. Multivariate regression analysis showed LA enlargement in athletes was largely explained by left ventricular cavity enlargement (R2 = 0.53) and participation in dynamic sports (such as cycling, rowing/canoeing) but minimally by body size. Conclusions In a large population of highly trained athletes, enlarged LA dimension > or = 40 mm was relatively common (20%), with the upper limits of 45 mm in women and 50 mm in men distinguishing physiologic cardiac remodeling ("athlete's heart") from pathologic cardiac conditions. Atrial fibrillation and other supraventricular tachyarrhythmias proved to be uncommon (prevalence < 1%) and similar to that in the general population, despite the frequency of LA enlargement. Left atrial remodeling in competitive athletes may be regarded as a physiologic adaptation to exercise conditioning, largely without adverse clinical consequences.
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LA enlargement, both in size and volume, is associated with an increased risk of AF and is present in approximately 20% of young competitive athletes.
“Specifically, LA enlargement, both in size and volume, which is associated with an increased risk of AF, is present in approximately 20% of young competitive athletes [13,50].”
From Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature (2024) · cites this paper as [50]
The Abstract reports LA enlargement in 20% of competitive athletes, measured by transverse dimension, not volume. It describes LA enlargement as an AF predictor in the general population, but the Results found AF equally prevalent in athletes with enlarged and normal-sized LAs (0.3% in each group). Thus the cited study does not support increased AF risk from LA enlargement in its athlete cohort. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTheories suggest that complex mechanisms may contribute to AF, including alterations in autonomic tone, systemic inflammation, electrical remodeling, and LA enlargement and fibrosis.
“Theories suggest that complex mechanisms may contribute to AF, including alterations in autonomic tone, systemic inflammation, electrical remodeling, and LA enlargement and fibrosis [12,44,45,46,47,48,49,50].”
From Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature (2024) · cites this paper as [50]
The Abstract identifies LA enlargement as a predictor of atrial fibrillation in the general population, and the Discussion describes a theory linking enlargement to AF in athletes. The paper does not address systemic inflammation, electrical remodeling, or fibrosis as proposed mechanisms; its own athlete data found that LA enlargement did not predispose to supraventricular tachyarrhythmias. (LLM, conf=0.85)
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Cites
Echocardiographic predictors of nonrheumatic atrial fibrillation. The Framingham Heart Study.
Vaziri, S. M., Larson, M. G., Benjamin, E. J., & Levy, D. (1994) · Circulation · doi:10.1161/01.cir.89.2.724 · Cited by 1,073 · see citing works
Tsang, T. S. M., Barnes, M. E., Bailey, K. R., Leibson, C. L., Montgomery, S. C., Takemoto, Y., Diamond, P. M., Marra, M. A., Gersh, B. J., Wiebers, D. O., et al. (2001) · Mayo Clinic Proceedings · doi:10.4065/76.5.467 · Cited by 631 · see citing works
Prevention of atrial fibrillation after cardioversion: results of the PAFAC trial
FETSCH, T. (2004) · European Heart Journal · doi:10.1016/j.ehj.2004.04.015 · Cited by 334 · see citing works
Biffi, A., Pelliccia, A., Verdile, L., Fernando, F., Spataro, A., Caselli, S., Santini, M., & Maron, B. J. (2002) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(02)01977-0 · Cited by 315 · see citing works
Self-citationAtrial fibrillation and stroke: new ideas, persisting dilemmas
Halperin, J. L., & Hart, R. G. (1988) · Stroke · doi:10.1161/01.str.19.8.937 · Cited by 231 · see citing works
Paroxysmal atrial fibrillation in male endurance athletes. A 9-year follow up
Hoogsteen, J. (2004) · Europace · doi:10.1016/j.eupc.2004.01.004 · Cited by 134 · see citing works
Report of the NASPE Policy Conference on Arrhythmias and the Athlete
ESTES, N. A. M., LINK, M. S., CANNOM, D., NACCARELLI, G. V., PRYSTOWSKY, E. N., MARON, B. J., & OLSHANSKY, B. (2001) · Journal of Cardiovascular Electrophysiology · doi:10.1046/j.1540-8167.2001.01208.x · Cited by 95 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 25
- Olivotto I, Cecchi F, Casey SA, Dolora A, Traverse JH, Maron BJ. Impact of atrial fibrillation on the clinical course of hypertrophic cardiomyopathy. Circulation 2001;104:2517-24.
- Gavazzi A, De Maria R, Renosto G, et al. The spectrum of left ventricular size in dilated cardiomyopathy: clinical correlates and prognostic implications. SPIC (Italian Multicenter Cardiomyopathy Study) Group. Am Heart J 1993;125:410 -22.
- Kopecky SL, Gersh BJ, McGoon MD, et al. The natural history of lone atrial fibrillation: a population-based study over three decades. N Engl J Med 1987;317:669 -74.
- Benjamin EJ, D'Agostino RB, Belanger AJ, Wolf PA, Levy D. Left atrial size and the risk of stroke and death: the Framingham Heart Study. Circulation 1995;92:835-41.
- Coumel P. Autonomic influences in atrial tachyarrhythmias. J Car- diovasc Electrophysiol 1996;7:999 -1007.
- Link MS, Wang PJ, Estes NA III. Cardiac arrhythmias and electro- physiologic observations in the athlete. In: Williams R, editor. The Athlete and Heart Disease. Philadelphia, PA: Lippincott Williams & Wilkins, 1998:197-216.
- Jensen-Urstad K. High prevalence of arrhythmias in elderly male athletes with a lifelong history of regular strenuous exercise. Heart 1998;79:161-4.
- Mont L, Sambola A, Brugada J, et al. Long-lasting sport practice and lone atrial fibrillation. Eur Heart J 2002;23:477-82.
- Coumel P. Atrial fibrillation: one more sporting inconvenience? Eur Heart J 2002;23:431-3.
- Toutouzas K, Trikas A, Pitsavos C, et al. Echocardiographic features of left atrium in elite male athletes. Am J Cardiol 1996;78:1314 -7.
- Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30 year Italian experi- ence. Am J Cardiol 1995;75:827-8. 695 JACC Vol. 46, No. 4, 2005 Pelliccia et al. August 16, 2005:690-6 Left Atrial Remodeling in Competitive Athletes
- Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999; 130:23-31.
- Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978;58: 1072-83.
- Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med 1991;324:295-301.
- Feigenbaum H. Echocardiography. 4th edition. Philadelphia, PA: Lea & Febiger; 1986:622.
- Ford LE. Heart size. Circ Res 1976;39:297-303.
- Maron BJ, Spirito P, Green KJ, Wesley YE, Bonow RO, Arce J. Noninvasive assessment of left ventricular diastolic function by pulsed Doppler echocardiography in patients with hypertrophic cardiomyop- athy. J Am Coll Cardiol 1987;10:733-42.
- Armitage P, Berry G. Statistical Methods in Medical Research. Oxford: McGraw-Hill Publications, 1994:277.
- Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000;102:278 -84.
- Henry WL, Gardin JM, Ware JH. Echocardiographic measurements in normal subjects from infancy to old age. Circulation 1980;62:1054 - 61.
- Rose G, Baxter PJ, Reid DD, McCartney P. Prevalence and prognosis of electrocardiographic findings in middle-aged men. Br Heart J 1978;40:636 -43.
- Kannel WB, Abbott RD, Savage DD, McNamara PM. Epidemiologic features of chronic atrial fibrillation. The Framingham Study. N Engl J Med 1982;306:1018 -22.
- Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA 2002;287:1308 -20.
- Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recom- mendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005;45:2-64.
- Ganau A, Devereux RB, Roman MJ, et al. Patterns of left ventricular hypertrophy and geometric remodeling in essential hypertension. J Am Coll Cardiol 1992;19:1550 -8.
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Abdulla, J., & Nielsen, J. R. (2009) · Europace · doi:10.1093/europace/eup197 · Cited by 420 · see citing works
Franklin, B. A., Thompson, P. D., Al-Zaiti, S. S., Albert, C. M., Hivert, M.-F., Levine, B. D., Lobelo, F., Madan, K., Sharrief, A. Z., Eijsvogels, T. M. H., et al. (2020) · Circulation · doi:10.1161/cir.0000000000000749 · Cited by 410 · see citing works
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Ethnic Differences in Left Ventricular Remodeling in Highly-Trained Athletes
Basavarajaiah, S., Boraita, A., Whyte, G., Wilson, M., Carby, L., Shah, A., & Sharma, S. (2008) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2007.12.061 · Cited by 333 · see citing works
Molina, L., Mont, L., Marrugat, J., Berruezo, A., Brugada, J., Bruguera, J., Rebato, C., & Elosua, R. (2008) · EP Europace · doi:10.1093/europace/eun071 · Cited by 327 · see citing works
Atrial Fibrillation Promotion by Endurance Exercise
Guasch, E., Benito, B., Qi, X., Cifelli, C., Naud, P., Shi, Y., Mighiu, A., Tardif, J.-C., Tadevosyan, A., Chen, Y., et al. (2013) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2013.01.091 · Cited by 302 · see citing works
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Mont, L., Tamborero, D., Elosua, R., Molina, I., Coll-Vinent, B., Sitges, M., Vidal, B., Scalise, A., Tejeira, A., Berruezo, A., et al. (2008) · EP Europace · doi:10.1093/europace/eum263 · Cited by 270 · see citing works
Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes
Wilhelm, M., Roten, L., Tanner, H., Wilhelm, I., Schmid, J.-P., & Saner, H. (2011) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2011.03.086 · Cited by 192 · see citing works
Aschar-Sobbi, R., Izaddoustdar, F., Korogyi, A. S., Wang, Q., Farman, G. P., Yang, F., Yang, W., Dorian, D., Simpson, J. A., Tuomi, J. M., et al. (2015) · Nature Communications · doi:10.1038/ncomms7018 · Cited by 185 · see citing works
Grimsmo, J., Grundvold, I., Maehlum, S., & Arnesen, H. (2010) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1097/hjr.0b013e32833226be · Cited by 176 · see citing works
Lampert, R., Chung, E. H., Ackerman, M. J., Arroyo, A. R., Darden, D., Deo, R., Dolan, J., Etheridge, S. P., Gray, B. R., Harmon, K. G., et al. (2024) · Heart Rhythm · doi:10.1016/j.hrthm.2024.05.018 · Cited by 167 · see citing works
Long-Term Clinical Consequences of Intense, Uninterrupted Endurance Training in Olympic Athletes
Pelliccia, A., Kinoshita, N., Pisicchio, C., Quattrini, F., DiPaolo, F. M., Ciardo, R., Di Giacinto, B., Guerra, E., De Blasiis, E., Casasco, M., et al. (2010) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2009.10.068 · Cited by 159 · see citing works
Self-citationDiagnosis, pathophysiology, and management of exercise-induced arrhythmias
Guasch, E., & Mont, L. (2017) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2016.173 · Cited by 134 · see citing works
Hein, H., Panhuyzen-Goedkoop, N., Corrado, D., Hoffmann, E., Biffi, A., Delise, P., Blomstrom-Lundqvist, C., Vanhees, L., IvarHoff, P., Dorwarth, U., et al. (2006) · European Journal of Cardiovascular Prevention & Rehabilitation · doi:10.1097/01.hjr.0000216543.54066.72 · Cited by 134 · see citing works
Self-citationEfficacy of circumferential pulmonary vein ablation of atrial fibrillation in endurance athletes
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Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation
Koopman, P., Nuyens, D., Garweg, C., La Gerche, A., De Buck, S., Van Casteren, L., Alzand, B., Willems, R., & Heidbuchel, H. (2011) · Europace · doi:10.1093/europace/eur142 · Cited by 102 · see citing works
Atrial fibrillation in endurance athletes
Wilhelm, M. (2014) · European Journal of Preventive Cardiology · doi:10.1177/2047487313476414 · Cited by 95 · see citing works
Swanson, D. R. (2006) · Medical Hypotheses · doi:10.1016/j.mehy.2006.01.006 · Cited by 81 · see citing works
Atrial fibrillation in athletes and the interplay between exercise and health
Gerche, A. L., & Schmied, C. M. (2013) · European Heart Journal · doi:10.1093/eurheartj/eht265 · Cited by 78 · see citing works
Vagal atrial fibrillation: What is it and should we treat it?
Carpenter, A., Frontera, A., Bond, R., Duncan, E., & Thomas, G. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2015.08.108 · Cited by 65 · see citing works
Atrial Fibrillation in Athletes
Estes, N. A. M., & Madias, C. (2017) · JACC: Clinical Electrophysiology · doi:10.1016/j.jacep.2017.03.019 · Cited by 56 · see citing works
Impact of ethnicity on cardiac adaptation to exercise
Sheikh, N., & Sharma, S. (2014) · Nature Reviews Cardiology · doi:10.1038/nrcardio.2014.15 · Cited by 44 · see citing works
Arrhythmias and sport practice
Mont, L. (2010) · Heart · doi:10.1136/hrt.2008.160903 · Cited by 38 · see citing works
Ayinde, H., Schweizer, M. L., Crabb, V., Ayinde, A., Abugroun, A., & Hopson, J. (2018) · IJC Heart & Vasculature · doi:10.1016/j.ijcha.2018.01.002 · Cited by 32 · see citing works
Managing athletes with palpitations of unknown origin with an external loop recorder: A cohort study
SCIARRA, L., CAVARRETTA, E., SICILIANI, S., SETTE, A., SCARÀ, A., GRIECO, D., DE RUVO, E., PALAMÀ, Z., NESTI, M., ROMANO, S., et al. (2022) · The Journal of Sports Medicine and Physical Fitness · doi:10.23736/s0022-4707.21.12831-2 · Cited by 15 · see citing works
Self-citationAtrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature
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“Theories suggest that complex mechanisms may contribute to AF, including alterations in autonomic tone, systemic inflammation, electrical remodeling, and LA enlargement and fibrosis [12,44–50].”
Background
- Authors
- Pelliccia, A., Maron, B. J., Di Paolo, F. M., Biffi, A., Quattrini, F. M., Pisicchio, C., Roselli, A., Caselli, S., & Culasso, F.
- Affiliations
- National Research Council (IT)
- Minneapolis Heart Institute Foundation (US)
- Sapienza University of Rome (IT)
- Corresponding author
- Pelliccia, Antonio
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2005-08
- Volume
- 46
- Issue
- 4
- Pages
- 690-696
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2154356012
- Cited by
- 443
- References
- 7
- Citations by year
- 2026: 9 · 2025: 14 · 2024: 13 · 2023: 17 · 2022: 26 · 2021: 19 · 2020: 27 · 2019: 15 · 2018: 31 · 2017: 25 · 2016: 30 · 2015: 30 · 2014: 28 · 2013: 27 · 2012: 31
- FWCI
- 9.59
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- IRIS Research product catalog (Sapienza University of Rome) (submittedVersion)
- INFM-OAR (INFN Catania) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Keywords
- left atrial remodeling, athlete's heart, left atrial enlargement, competitive athletes, supraventricular tachyarrhythmias, paroxysmal atrial fibrillation, left ventricular dilatation, exercise training, sex differences, structural heart disease
- MeSH terms
- Adaptation, Physiological, Adolescent, Adult, Atrial Fibrillation, Diagnosis, Differential, Echocardiography, Female, Heart Atria, Humans, Italy, Male, Sports, Tachycardia, Supraventricular, Prevalence, Ventricular Remodeling
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