Atrial fibrillation in athletes and the interplay between exercise and health
Open accessAbstract
This editorial refers to ‘Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study’†, by K. Andersen et al., on page 3624 Exercise is one of the most powerful lifestyle intervention strategies for the primary and secondary prevention of cardiovascular disease. There is a wealth of evidence regarding the lower ranges of the exercise dose–response relationship providing concrete evidence for the current recommendations of at least 30 min of moderate intensity exercise on most days as a means of reducing cardiovascular events.1 However, there is an increasing proportion of today's society engaging in sports practices which vastly exceed these guidelines, and there has been very limited study of the upper ranges of the exercise dose–response relationship.2 On the one hand are studies suggesting that long-term health and life expectancy of well-trained athletes is superior to that of the general population,3−5 while, on the other, there is evidence suggesting an increased prevalence of arrhythmias and chronic structural remodelling of the athletic heart.6−9 Atrial fibrillation (AF) may therefore represent the most intriguing and best evidenced example of the interplay between exercise and cardiac health. AF can be diagnosed in ∼1% of the population by age 60 and in >10% when older than 80 years,10 making it the most prevalent sustained arrhythmia in adults. In cohorts of young or middle-aged subjects, AF is relatively uncommon, thus implying that large cohorts would be required to provide sufficient power to identify any excess in prevalence due to sports practice. In this context, it is not surprising that Pelliccia et al. found only very few cases of AF despite significant left atrial enlargement in a fairly large (n = 1777) athletic cohort aged 24 ± 6 years.11 In contrast, Baldesberger et al. were able to identify an excess of AF when comparing a small cohort of 62 former professional cyclists with 62 ex-golfers aged 66 ± 7 years.6 Although one must always consider type 1 errors (false discoveries) in studies of small sample size, it may also be that a true exercise-induced excess in AF prevalence becomes appreciable when the cohort reaches an age in which AF is more common and when the amount of exercise practised is relatively extreme. In this context, the recent study of Andersen et al. is remarkable.12 The group of participants in the popular Vasaloppet 90 km cross-country ski race was young and healthy when one considers the likelihood of identifying incident AF. Less than 10% of the cohort was aged >60 years and those with significant co-morbidities were few, as evidenced by the exclusion of participants with known cardiovascular disease and by the fact that the cohort had better health behaviour and overall longevity than the average Swedish population.13 Many of the established risk factors for AF, such as hypertension, heart failure, diabetes, and obesity,14 are likely to be under-represented within this group of cross-country ski enthusiasts and, thus, we might expect such a low prevalence of AF that detecting any residual risk attributable to exercise dose would be difficult. However, the very large cohort size of 52 755 athletes and the creative measures of exercise enabled the authors to define a ‘dose–response’ curve that provides further circumstantial evidence for the premise that AF risk is increased in the very fittest athletes and in those who perform exercise over many years. Andersen et al. investigated the primary endpoint of any arrhythmia, which was a composite of brady- and tachyarrhythmias, and determined that those completing the race within 60% of the winner's time were 1.3 times more likely to be diagnosed with an arrhythmia than those who took more than twice the time to complete the race. Similarly, those who had completed the race ≥5 times had a 1.3-fold increase in arrhythmic risk as compared with those who completed the race only once. The primary endpoint was predominantly driven by AF, with a similar trend seen in bradyarrhythmias (though fewer events, making definitive conclusions difficult). There was no apparent association between exercise measures and supraventricular arrhythmias other than AF/atrial flutter, and there were too few ventricular arrhythmic events to draw conclusions. One of the biggest limitations when trying to interpret the data of Andersen et al. is trying to work out a reference point against which to interpret the described prevalence of arrhythmias. The lowest prevalence of arrhythmias was observed in the slowest athletes who had raced least; but what is the critical ‘cut-off’ concerning the amount of exercise that leads to an elevated risk for developing AF? We are frequently asked: ‘How many hours of exercise and at what intensity before I am at risk of AF?’, but there are numerous complexities which make it difficult to give prescriptive guidelines. First, as summarized in Figure 1, arrhythmias such as AF are the clinical
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A U-shaped relationship exists between male elite athletes and AF, suggesting both type (endurance) and dose (hours of training) of physical activity relate to AF development.
“A U-shaped relationship between male elite athletes and AF is demonstrated through this finding, suggesting that both the type (endurance) and the dose (hours of training) of physical activity seem to relate to AF development [14,18,19,20,21].”
From Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature (2024) · cites this paper as [21]
On p. 3624, Figure 2 and the accompanying discussion describe a U-shaped relationship between exercise dose and AF risk, and the paper reports an association between endurance exercise and AF. But the curve is a tentative synthesis of disparate studies, not a demonstrated relationship specifically in male elite athletes; the paper also says it cannot establish a threshold in hours of training. (LLM, conf=0.86)
Experimental — accuracy not yet measuredLack of physical activity and long-term vigorous exercise both increase the risk of developing atrial fibrillation, suggesting a U-shaped curve.
“with studies suggesting a U-shaped curve, with lack of physical activity and long-term vigourous exercise both increasing the risk of developing AF. 10 11”
From Risk of atrial fibrillation in athletes: a systematic review and meta-analysis (2021) · cites this paper as [10]
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Self-citationHopman, L. H. G. A., Smedema, J., Swart, J., Steenhoek, M. J., Frenaij, I. M., Dahya, V., & Götte, M. (2025) · The International Journal of Cardiovascular Imaging · doi:10.1007/s10554-025-03416-8 · Cited by 4 · see citing works
Atrial fibrillation among master athletes: A complex relationship
Sciarra, L., D’Ascenzi, F., Borrelli, A., Santarelli, M., Fusari, M., Scognamiglio, D., Zanin, F., Pignalosa, L., Spiriti, G., Petrungaro, M., et al. (2026) · International Journal of Cardiology · doi:10.1016/j.ijcard.2026.134212 · Cited by 2 · see citing works
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Demi̇r, R. (2023) · doi:10.5152/0114 · Cited by 2 · see citing works
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Berent, R. (2015) · Springer eBooks · doi:10.1007/978-3-662-43711-7_10 · Cited by 2 · see citing works
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Health and lifestyle risk factors: a comparison between Brazilian athletes and non-athletes
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Diretriz Brasileira de Fibrilação Atrial – 2025
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Exercise-Induced Right Heart Disease in Athletes
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Self-citationAtrial fibrillation in elite athletes. What is missing?
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Atrial Fibrillation: Should Lifelong Athletes Be Worried?
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Medikamentöse Therapie des Vorhofflimmerns in speziellen Situationen
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Kronik Koroner Sendromlar ve Spor Kardiyolojisi
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Self-citation
- Authors
- Gerche, A. L., & Schmied, C. M.
- Affiliations
- The University of Melbourne (AU)
- University Hospital Zurich (CH)
- Corresponding author
- Schmied, C. M.
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2013-07-24
- Volume
- 34
- Issue
- 47
- Pages
- 3599-3602
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W2102870177
- Cited by
- 78
- References
- 31
- Citations by year
- 2026: 1 · 2025: 9 · 2024: 6 · 2023: 20 · 2022: 5 · 2021: 4 · 2020: 6 · 2019: 1 · 2018: 4 · 2017: 2 · 2016: 3 · 2015: 6 · 2014: 10
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Heart Journal (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- reroDoc Digital Library (submittedVersion)
- HighWire Press Open Archive (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Keywords
- atrial fibrillation, athletes, exercise-induced arrhythmia, cross-country skiers, athlete's heart, left atrial enlargement, exercise dose-response, cardiovascular risk, arrhythmia risk, endurance sports, left atrial fibrosis, professional cyclists
- MeSH terms
- Arrhythmias, Cardiac, Female, Humans, Male, Skiing
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