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Cited by 7Cardiovascular Effects of ExerciseAtrial Fibrillation Management and OutcomesCardiac electrophysiology and arrhythmias

Atrial Fibrillation in Elite Athletes: A Comprehensive Review of the Literature

Open access
Kourek, Christos, Briasoulis, Alexandros, Tsougos, Elias, Paraskevaidis, Ioannis·2024·Journal of Cardiovascular Development and Disease
DOI 10.3390/jcdd11100315PMC PMC11508555
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Abstract

Although the benefits of exercise training have been shown repeatedly in many studies, its relationship with the occurrence of atrial fibrillation (AF) in competitive athletes still remains controversial. In the present review, we sought to demonstrate a comprehensive report of the incidence, pathophysiology, and therapeutic approaches to AF in elite athletes. A 2 to 10 times higher frequency of AF has been shown in many studies in high-intensity endurance athletes compared to individuals who do not exercise. Moreover, a U-shaped relationship between male elite athletes and AF is demonstrated through this finding, while the type and the years of physical activity seem to relate to AF development. A strong correlation seems to exist among the type of exercise (endurance sports), age (>55 years), gender (males), and the time of exercise training, all contributing to an increased risk of AF. The pathophysiology of AF still remains unclear; however, several theories suggest that complex mechanisms are involved, such as bi-atrial dilatation, pulmonary vein stretching, cardiac inflammation, fibrosis, and increased vagal tone. Elite athletes with AF require a comprehensive clinical evaluation and risk factor optimization, similar to the approach taken for nonathletes. Although anticoagulation and rate or rhythm control are cornerstones of AF management, there are still no specific guidelines for elite athletes.

AI snapshot

Written from the paper’s full text.

TL;DR

This comprehensive review reports that elite endurance athletes have a 2–10 times higher frequency of atrial fibrillation (AF) than non-exercisers, with a U-shaped relationship in men and multiple proposed mechanisms including atrial remodeling, inflammation, fibrosis, and increased vagal tone. Management follows general AF principles—anticoagulation and rate or rhythm control—but no elite-athlete-specific guidelines exist.

Key findings

  • High-intensity endurance athletes show a 2–10 times higher frequency of AF compared with individuals who do not exercise; a U-shaped relationship is described in male elite athletes but not confirmed in women. A meta-analysis of 13 studies including approximately 64,000 athletes found athletes were 2.46 times more likely to have prevalent AF (95% CI 1.73–3.51), rising to an odds ratio of 3.6 for athletes aged <55 years; mixed sports had greater AF burden than endurance sports (B = −0.5476, p = 0.0204).
  • In a 20-year retrospective cohort of 6813 young elite Spanish athletes (mean age 22), AF incidence was 0.3% (21/6813; 18 paroxysmal, 1 persistent, 2 long-standing persistent), and increased AF risk was associated with years of exercise training, age, and left atrial anteroposterior diameter. Prevalence of AF in competitive athletes ranges from 0.3% to approximately 13%.
  • Proposed mechanisms include bi-atrial dilatation, pulmonary vein stretching, cardiac inflammation, fibrosis, and increased vagal tone. Fibrosis markers were higher in veteran elite athletes than sedentary controls: CITP 5.4 vs. 2.9 microg/L (p < 0.001), PICP 259 vs. 166 microg/L (p < 0.001), and TIMP-1 350 vs. 253 ng/mL (p = 0.01). In 492 marathon runners, left atrial enlargement correlated with training hours (24% <1500 h, 40% 1500–4500 h, 83% >4500 h).
  • Each 10 years of endurance exercise was associated with 1.16 times higher AF risk (95% CI 1.06–1.29) and 1.42 times higher atrial flutter risk (95% CI 1.20–1.69). Management uses anticoagulation and rate or rhythm control; a CHA2DS2-VA score ≥2 recommends oral anticoagulation, score 1 should also be considered, and athletes should not participate in sports for at least 1 month after successful ablation.

Methods

  • Comprehensive narrative review of the literature on incidence, pathophysiology, and therapeutic approaches to AF in elite athletes; no primary data collection or systematic search strategy is reported.
  • Synthesizes findings from retrospective observational studies, meta-analyses, cohort studies, randomized trials, and guidelines, including cited samples such as 6813 young elite Spanish athletes, approximately 64,000 athletes in a meta-analysis, 492 marathon runners, and 45 veteran elite athletes.
  • Main analysis is qualitative synthesis; no new statistical analysis is performed.

Limitations

  • Stated: the pathophysiology of AF in elite athletes remains unclear; there are no specific guidelines for elite athletes with AF, only consensus and recommendations; more studies with longer follow-up are required.
  • Stated: data on male–female differences are limited due to a lack of specific trials and reliance on small retrospective studies.
  • Evident: as a narrative review, it does not report a systematic search, risk-of-bias assessment, or meta-analysis, and its conclusions depend on heterogeneous cited studies; no primary data are presented.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3390/jcdd11100315

Cites

93 of 93 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

67 of 113 cited sources checked · 20 supported · 7 flagged · accuracy not yet measured

  • Premisecitation

    Retrospective studies with small sample sizes comparing men and women showed that AF incidence may be higher in female endurance athletes compared to males.

    “Only retrospective studies with small sample sizes that have been conducted over the last 2 decades, which compared men and women, showed that AF incidence may be higher in female endurance athletes compared to males [28,29].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [28] Drca, 2023, Elite female endurance athletes are at increased risk of atrial fibrillation compared to the general population: A matched cohort study, Br. J. Sports Med. source

      The Introduction says earlier studies found increased AF risk in male endurance athletes, while that association had not been observed in women. The Discussion > Limitations states that this study had no comparable male athlete cohort, so it could not directly compare men and women. Its finding concerns female athletes versus female controls, not higher AF incidence in women than men; page numbers were not available in our copy. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [29] Myrstad, 2024, Atrial fibrillation in female endurance athletes, Eur. J. Prev. Cardiol. source

      The study text indexed under Abstract describes a prospective cohort, not a retrospective study. It also says AF in female endurance athletes was lower than in male endurance athletes—the opposite of the cited claim. The paper reports cumulative prevalence rather than incidence. (LLM, conf=0.90)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    A 2 to 10 times higher frequency of AF has been shown in high-intensity endurance athletes compared to individuals who do not exercise.

    “Many retrospective observational studies and meta-analyses have estimated a 2 to 10 times higher frequency of AF in high-intensity endurance athletes compared to individuals who do not exercise [6,7,8,12,13,14,15,16,17].”
    Quote in the paperSubstantial claim4 of 9 sources checked
    • cites [6] Wilhelm, 2011, Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes, Am. J. Cardiol. source
    • cites [7] Mont, 2008, Physical activity, height, and left atrial size are independent risk factors for lone atrial fibrillation in middle-aged healthy individuals, Europace source

      The introduction and ‘Role of physical activity’ section state that previous studies link long-term endurance sport to increased AF risk. But this paper does not report a 2–10-fold higher AF frequency in high-intensity endurance athletes versus non-exercisers. Its Table 5 instead gives adjusted odds ratios of 5.60 and 15.11 for accumulated moderate and heavy physical activity relative to the lowest-activity group; those are not the claimed comparison or range. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [8] Myrstad, 2014, Effect of years of endurance exercise on risk of atrial fibrillation and atrial flutter, Am. J. Cardiol. source
    • cites [12] Estes, 2017, Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation, JACC Clin. Electrophysiol. source
    • cites [13] Lippi, 2017, Atrial fibrillation in highly trained endurance athletes—Description of a syndrome, Int. J. Cardiol. source
    • cites [14] Andersen, 2013, Risk of arrhythmias in 52 755 long-distance cross-country skiers: A cohort study, Eur. Heart J. source
    • cites [15] Mozaffarian, 2008, Physical activity and incidence of atrial fibrillation in older adults: The cardiovascular health study, Circulation source

      The Discussion reports that case series and retrospective studies suggest higher AF risk in long-term endurance athletes than in the general population. It does not give a 2-to-10-fold estimate, identify meta-analyses supporting that range, or establish that the comparison group did not exercise. The paper’s own Results concern older adults and do not show higher AF incidence with high-intensity exercise than with no regular exercise. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [16] Ofman, 2013, Regular physical activity and risk of atrial fibrillation: A systematic review and meta-analysis, Circ. Arrhythm. Electrophysiol. source
    • cites [17] Mohanty, 2016, Differential Association of Exercise Intensity with Risk of Atrial Fibrillation in Men and Women: Evidence from a Meta-Analysis, J. Cardiovasc. Electrophysiol. source
  • Premisecitation

    Physical activity has a dose-dependent J-shape effect on AF risk, with increased risk at very low and very high levels of physical activity.

    “A recent meta-analysis showed that physical activity has a dose-dependent J-shape effect on AF risk, with increased risk at very low and very high levels of physical activity [15].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [15] Mozaffarian, 2008, Physical activity and incidence of atrial fibrillation in older adults: The cardiovascular health study, Circulation source

      The Results report a nonlinear, U-shaped association for exercise intensity in older adults: moderate exercise was associated with lower AF risk than no regular exercise. But high-intensity exercise was not associated with significantly higher risk than no exercise, and the Discussion explicitly describes it as having a neutral association. This paper is a prospective cohort study, not a meta-analysis; its leisure-time activity measure showed graded lower risk rather than a J-shaped pattern. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Athletes participating in mixed sports have increased AF burden compared to those engaged in endurance sports (B = −0.5476, p = 0.0204).

    “Athletes participating in mixed sports (such as football, basketball, and American football) have increased AF burden compared to those engaged in endurance sports (such as Nordic skiing, orienteering, and rowing; B = −0.5476, p = 0.0204) [25].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] Newman, 2021, Risk of atrial fibrillation in athletes: A systematic review and meta-analysis, Br. J. Sports Med. source
  • Premisecitation

    A study of 45 veteran elite athletes showed increased markers of myocardial fibrosis (CITP 5.4 vs. 2.9 microg/L, p < 0.001; PICP 259 vs. 166 microg/L, p < 0.001; TIMP-1 350 vs. 253 ng/mL, p = 0.01) compared to sedentary controls.

    “A study including 45 veteran elite athletes showed increased markers of myocardial fibrosis, such as carboxyterminal telopeptide of collagen type I (CITP 5.4 vs. 2.9 microg/L, p < 0.001), plasma carboxyterminal propeptide of collagen type I (PICP 259 vs. 166 microg/L, p < 0.001), and tissue inhibitor of matrix metalloproteinase type I (350 vs. 253 ng/mL, p = 0.01), compared to sedentary controls [”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [53] Lindsay, 2007, Biochemical evidence of myocardial fibrosis in veteran endurance athletes, Br. J. Sports Med. source
  • May combine two claims. 44
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 9

  • May combine two claims.

    Premisecitation

    There is a strong association between AF and genes KCNA5, SCN5A, and TTN, while LMNA and KCNQ1 present a weaker association with AF.

    “There is a strong association between AF and genes such as KCNA5, SCN5A and TTN, while genes like LMNA and KCNQ1 present a weaker association with AF [35,36,37,38].”
    Quote in the paperNot a substantial claim4 of 4 sources checked
    • cites [35] Chalazan, 2023, Genetic testing in monogenic early-onset atrial fibrillation, Eur. J. Hum. Genet. source
    • cites [36] Yoneda, 2021, Early-Onset Atrial Fibrillation and the Prevalence of Rare Variants in Cardiomyopathy and Arrhythmia Genes, JAMA Cardiol. source

      The Discussion’s “Prevalence of Disease-Associated Variants in Individual Genes” section reports that TTN variants were the most common among patients with early-onset AF (27% of disease-associated variants), while LMNA and KCNQ1 each accounted for 6%. That supports a narrower comparison of variant frequencies, not a comparison of the genes’ strength of association with AF. The passages found do not establish the claimed strong associations for KCNA5 or SCN5A. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [37] Hateley, 2021, The history and geographic distribution of a KCNQ1 atrial fibrillation risk allele, Nat. Commun. source

      The Introduction describes KCNQ1 R231H as a high-impact AF susceptibility allele, and the Discussion reports relatively high penetrance—79% by adulthood—in the studied family. That runs contrary to the claim’s characterization of KCNQ1 as weakly associated with AF. The paper does not compare KCNQ1’s association with the other genes named in the citing sentence. (LLM, conf=0.80)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [38] Lampert, 2024, 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play, Heart Rhythm. source

  • May combine two claims.

    Premisecitation

    The J-shape effect of physical activity on AF risk is gender-specific and more pronounced in younger males.

    “This effect seems to be gender-specific and more pronounced in younger males.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [15] Mozaffarian, 2008, Physical activity and incidence of atrial fibrillation in older adults: The cardiovascular health study, Circulation source

      The Results (Assessment of Confounding by Comorbidity; page unavailable) report little evidence that the association between physical activity and AF varied by age or gender. Although the paper finds a U-shaped association for exercise intensity in older adults, it does not find the claimed stronger effect in younger males. (LLM, conf=0.90)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Although the prevalence of AF increases with age, the relative risk for athletes compared to nonathletes is higher in younger athletes.

    “Moreover, although the prevalence of AF increases with age, the relative risk for athletes compared to nonathletes seems to be higher in younger athletes [22,23].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [22] Johansen, 2022, Risk of atrial fibrillation and stroke among older men exposed to prolonged endurance sport practice: A 10-year follow-up. The Birkebeiner Ageing Study and the Tromsø Study, Open Heart source

      The Discussion (Long-term endurance sport practice and risk of atrial fibrillation; page unavailable) compares an 11% increase in middle-aged skiers with a near-twofold increase in this study’s older athletes. It suggests the athlete–nonathlete risk difference may be magnified with age—the opposite of the claimed age pattern. The Results report elevated AF risk in older athletes but do not show a higher relative risk in younger athletes. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [23] Svedberg, 2019, Long-Term Incidence of Atrial Fibrillation and Stroke Among Cross-Country Skiers, Circulation source

      The Discussion says earlier reports found age important to AF development in male athletes, but it does not say whether younger athletes have a higher relative risk than older athletes compared with nonathletes. The Results compare skiers with nonskiers by sex, not by age; searches for younger skiers and age-dependent relative risk found no age-stratified comparison in our copy. (LLM, conf=0.72)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Regular exercise of low or moderate intensity serves as a preventive strategy for cardiovascular disease and AF, while higher-intensity endurance exercise may lead to AF.

    “Regular exercise of either low or moderate intensity seems serve as a preventive strategy for cardiovascular disease and AF, while higher-intensity endurance exercise may lead to AF [6,7,8,12,13,14,15,16,17,18,19,20,21].”
    Quote in the paperSubstantial claim5 of 10 sources checked
    • cites [6] Wilhelm, 2011, Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes, Am. J. Cardiol. source

      The Abstract and Discussion report increased AF risk among endurance athletes and AF episodes in the medium- and high-training groups. They do not say that low- or moderate-intensity exercise prevents cardiovascular disease or AF; the study groups are defined by lifetime training hours, not exercise intensity. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [7] Mont, 2008, Physical activity, height, and left atrial size are independent risk factors for lone atrial fibrillation in middle-aged healthy individuals, Europace source

      The Physical activity and Role of physical activity sections report that moderate activity was higher in patients with lone AF and was associated with it, contrary to the claim that moderate exercise prevents AF. The paper does support the other parts: it treats exercise as a way to prevent coronary artery disease and warns that prolonged, intense activity may increase AF risk. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [8] Myrstad, 2014, Effect of years of endurance exercise on risk of atrial fibrillation and atrial flutter, Am. J. Cardiol. source
    • cites [12] Estes, 2017, Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation, JACC Clin. Electrophysiol. source
    • cites [13] Lippi, 2017, Atrial fibrillation in highly trained endurance athletes—Description of a syndrome, Int. J. Cardiol. source
    • cites [14] Andersen, 2013, Risk of arrhythmias in 52 755 long-distance cross-country skiers: A cohort study, Eur. Heart J. source
    • cites [15] Mozaffarian, 2008, Physical activity and incidence of atrial fibrillation in older adults: The cardiovascular health study, Circulation source

      The Results and Discussion report lower AF incidence with moderate activity in older adults, and the Discussion reports a possible increase in AF with endurance exercise among younger and middle-aged people. But this study found no increased AF risk with high-intensity exercise in its older cohort. It also does not establish low- or moderate-intensity exercise as a preventive strategy for cardiovascular disease generally; the AF finding is observational. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [16] Ofman, 2013, Regular physical activity and risk of atrial fibrillation: A systematic review and meta-analysis, Circ. Arrhythm. Electrophysiol. source
    • cites [17] Mohanty, 2016, Differential Association of Exercise Intensity with Risk of Atrial Fibrillation in Men and Women: Evidence from a Meta-Analysis, J. Cardiovasc. Electrophysiol. source
    • cites [18] Petrungaro, M., Fusco, L., Cavarretta, E., Scarà, A., Borrelli, A., Romano, S., Petroni, R., D’Ascenzi, F., and Sciarra, L. (2023). Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship. J. Cardiovasc. Dev. Dis., 10. source

  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    In a meta-analysis of 12 studies with 670 participants, all exercise modalities (aerobic exercise, AIT, yoga, qigong, cardiac rehabilitation) demonstrated statistically significant beneficial effects on general health and vitality measured by SF-36; cardiac rehabilitation and AIT increased peak VO2, AIT reduced AF burden, and qigong improved the 6-min walk test.

    “All exercise modalities demonstrated statistically significant beneficial effects on general health and vitality, measured by the Short Form 36-item questionnaire.”
    • Also stated in: § 4. Clinical Significance, Screening and Management · plain
      “Specifically, cardiac rehabilitation protocols and AIT increased peak VO2, while AIT also significantly reduced AF burden. Moreover, qigong significantly improved the 6-min walk test in these individuals [78].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [78] AbuElkhair, 2023, Effects of different exercise types on quality of life for patients with atrial fibrillation: A systematic review and meta-analysis, J. Cardiovasc. Med. source

      Split into 2 atoms — 0 confirmed, 1 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Theories 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].”
    Quote in the paperNot a substantial claim5 of 8 sources checked
    • cites [12] Estes, 2017, Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation, JACC Clin. Electrophysiol. source
    • cites [44] Elliott, 2016, Atrial Fibrillation in Endurance Athletes: From Mechanism to Management, Cardiol. Clin. source
    • cites [45] Nattel, 2014, Atrial remodeling and atrial fibrillation: Recent advances and translational perspectives, J. Am. Coll. Cardiol. source

      The Overview, Autonomic Nervous System Changes, and Structural Remodeling sections support electrical remodeling, autonomic changes, and atrial enlargement and fibrosis as AF-promoting mechanisms. The Signaling Systems section discusses inflammation and proinflammatory genes in atrial remodeling, but does not identify systemic inflammation specifically as a contributor to AF. No page numbers are provided in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [46] La Gerche, A., Inder, W.J., Roberts, T.J., Brosnan, M.J., Heidbuchel, H., and Prior, D.L. (2015). Relationship between Inflammatory Cytokines and Indices of Cardiac Dysfunction following Intense Endurance Exercise. PLoS ONE, 10. source

      The Discussion (page unavailable) suggests that inflammatory mediators may contribute to arrhythmias and cites an association between IL-6 and atrial fibrillation. The cited paper does not identify altered autonomic tone, electrical remodeling, or left atrial enlargement and fibrosis as AF mechanisms. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [47] Sugama, 2015, Changes of thioredoxin, oxidative stress markers, inflammation and muscle/renal damage following intensive endurance exercise, Exerc. Immunol. Rev.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [48] Izaddoustdar, 2015, Increased atrial arrhythmia susceptibility induced by intense endurance exercise in mice requires TNFα, Nat. Commun. source

      The Abstract and Results sections link altered parasympathetic activity, atrial enlargement, fibrosis, inflammation, and electrical changes to AF susceptibility. However, the paper’s findings concern atrial inflammation and enlargement in intensely exercised mice; they do not establish systemic inflammation or specifically left-atrial enlargement as contributing mechanisms. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [49] Baggish, 2015, Mechanisms underlying the cardiac benefits of exercise: Still running in the dark, Trends Cardiovasc. Med. source
    • cites [50] Pelliccia, 2005, Prevalence and clinical significance of left atrial remodeling in competitive athletes, J. Am. Coll. Cardiol. source

      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)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The highest incidence of AF is observed in the Caucasian population compared to other racial groups.

    “Finally, studies indicate that the highest incidence of AF is observed in the Caucasian population compared to other racial groups [33,34].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [33] Norby, 2021, Racial and Ethnic Considerations in Patients with Atrial Fibrillation: JACC Focus Seminar 5/9, J. Am. Coll. Cardiol. source

      The Epidemiology section says US longitudinal cohort studies found the highest AF incidence in White individuals, and UK data show higher incidence in White than in Asian or Black individuals. The claim is broader than those findings: the same section reports a California study in which American Indians had a higher adjusted risk of incident AF than White individuals. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [34] Gomez, 2023, Racial, ethnic, and sex disparities in atrial fibrillation management: Rate and rhythm control, J. Interv. Card. Electrophysiol. source

  • May combine two claims.

    Premisecitation

    An association among endurance sports, age >55 years, male gender, and duration of exercise training with increased AF risk has been proven through studies.

    “An association among the type of exercise (endurance sports), age (>55 years), gender (males), and the duration of exercise training with increased AF risk has been proven through studies [24].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [24] Boraita, 2018, Incidence of Atrial Fibrillation in Elite Athletes, JAMA Cardiol. source

      Table 2 (page not provided) associates increasing age and years of competition with AF in multivariate analysis; male sex and endurance sport are associated only in univariate analysis and are nonsignificant in the multivariate model. The table gives an age cutoff of 27 years, not >55 years. The observational findings do not establish that these factors have been proven to increase risk. (LLM, conf=0.89)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In a meta-analysis of 13 studies including approximately 64,000 athletes, athletes were 2.46 times more likely to have prevalent AF (95% CI 1.73 to 3.51), and this odds ratio increased to 3.6 for athletes aged <55 years.

    “A large meta-analysis of 13 studies, including approximately 64,000 athletes, showed that athletes were 2.46 times more likely to have prevalent AF (95% CI 1.73 to 3.51). This odds ratio increased to 3.6 for athletes aged <55 years of age [25].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [25] Newman, 2021, Risk of atrial fibrillation in athletes: A systematic review and meta-analysis, Br. J. Sports Med. source

      The Primary analysis reports an AF odds ratio of 2.46 (95% CI 1.73 to 3.51), and the Subgroup analysis reports 3.60 for younger athletes. But Study and participant characteristics says the 13 studies included 70,478 participants—6,816 athletes and 63,662 controls—not approximately 64,000 athletes. The passages found describe the subgroup as ‘younger athletes’ without establishing the claimed <55-year cutoff. (LLM, conf=0.92)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The prevalence of AF in competitive athletes ranges from 0.3% to approximately 13%, differing according to age and modality of exercise training.

    “The prevalence of AF in competitive athletes ranges from 0.3% to approximately 13%, and differs according to the age and the modality of exercise training [13,25,26,27].”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [13] Lippi, 2017, Atrial fibrillation in highly trained endurance athletes—Description of a syndrome, Int. J. Cardiol. source
    • cites [25] Newman, 2021, Risk of atrial fibrillation in athletes: A systematic review and meta-analysis, Br. J. Sports Med. source

      The Subgroup analysis (page unavailable) reports different relative AF risks for younger and older athletes, and the Discussion (page unavailable) reports a relationship between exercise mode and AF risk. Neither section reports the claimed prevalence range of 0.3% to approximately 13%; searches for both figures found no supporting passage in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [26] Wernhart, 2015, Atrial fibrillation and long-term sports practice: Epidemiology and mechanisms, Clin. Res. Cardiol. source
    • cites [27] Calvo, 2016, Emerging risk factors and the dose-response relationship between physical activity and lone atrial fibrillation: A prospective case-control study, Europace source

      The Results (Sport activity; page unavailable) report different AF odds for endurance versus team sports and an univariate association with age at the start of vigorous exercise. They do not report AF prevalence among competitive athletes or the claimed 0.3%–13% range; the case–control study’s percentages cannot establish population prevalence. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Sports supplements containing high concentrations of caffeine and stimulants such as taurine and guarana may cause cardiac arrhythmias, including AF, after regular consumption, potentially by stimulating the autonomic system.

    “Other sports supplements that contain high concentrations of caffeine and stimulants, such as taurine and guarana, may cause cardiac arrhythmias after regular consumption, including AF, potentially by stimulating the autonomic system [41,42].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [41] Seifert, 2011, Health effects of energy drinks on children, adolescents, and young adults, Pediatrics source

      The Discussion identifies supraventricular and ventricular tachyarrhythmias as possible adverse effects of excessive caffeine, and the Conclusions warn of irregular heart rhythms from caffeine-containing products. The paper does not establish atrial fibrillation after regular consumption or autonomic stimulation as the mechanism; it says the effects of chronic use need further study and describes taurine as potentially suppressing sympathetic stimulation. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [42] During, 2011, Atrial fibrillation in healthy adolescents after highly caffeinated beverage consumption: Two case reports, J. Med. Case Rep. source

      The Introduction and Discussion report a possible association between highly caffeinated energy drinks and atrial fibrillation in two adolescents; the Discussion also mentions chronic caffeine use in one case. The paper distinguishes energy drinks from sports drinks and does not identify taurine or guarana as causes or propose autonomic-system stimulation as the mechanism. Its Introduction describes central and peripheral nervous-system stimulation by caffeine, but that does not establish the claimed mechanism for the arrhythmias. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Women exhibit greater bi-atrial deformation and smaller right atrial size compared to men in adaptation of atrial performance to training.

    “Another study by Sanchis et al. presented gender-related differences in the adaptation of atrial performance to training, with women exhibiting greater bi-atrial deformation and smaller right atrial size compared to men [31].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [31] Sanchis, 2017, Gender influence on the adaptation of atrial performance to training, Eur. J. Sport Sci. source

  • May combine two claims.

    Premisecitation

    There is a strong association between cardiomyopathies (dilated, hypertrophic, arrhythmogenic) and AF in younger athletes, with AF prevalence ranging from 10% to 25% in each subtype, as well as an association between LQTS, Brugada syndrome, and AF.

    “Another significant clue regarding the AF spectrum is the strong association between cardiomyopathies—including dilated, hypertrophic, and arrhythmogenic cardiomyopathy—and AF in younger athletes (with the prevalence of AF ranging from 10% to 25% in each subtype), as well as the association between long QT syndrome (LQTS), Brugada syndrome, and AF [32].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [32] Shoemaker, 2020, How Will Genetics Inform the Clinical Care of Atrial Fibrillation?, Circ. Res. source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the same cohort, increased AF risk was associated with years of exercise training, age, and left atrial anteroposterior diameter.

    “In the same study, there was an association between increased AF risk and years of exercise training, age, and left atrial (LA) anteroposterior diameter [24].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [24] Boraita, 2018, Incidence of Atrial Fibrillation in Elite Athletes, JAMA Cardiol. source

  • May combine two claims.

    Premisecitation

    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].”
    Quote in the paperSubstantial claim3 of 5 sources checked
    • cites [14] Andersen, 2013, Risk of arrhythmias in 52 755 long-distance cross-country skiers: A cohort study, Eur. Heart J. source
    • cites [18] Petrungaro, M., Fusco, L., Cavarretta, E., Scarà, A., Borrelli, A., Romano, S., Petroni, R., D’Ascenzi, F., and Sciarra, L. (2023). Long-Term Sports Practice and Atrial Fibrillation: An Updated Review of a Complex Relationship. J. Cardiovasc. Dev. Dis., 10. source

      The Discussion (§5; page not supplied) describes a possible U-shaped relationship between physical activity and AF and says sport type, intensity, and duration may matter. Section 3 reports increased AF risk in men practicing endurance sports. The review does not demonstrate a U-shaped relationship specifically in male elite athletes; it presents that relationship as a possibility reported by other studies. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [19] Morseth, 2016, Physical activity, resting heart rate, and atrial fibrillation: The Tromsø Study, Eur. Heart J. source

      The Introduction (page unavailable) links endurance training to AF and notes high AF prevalence in male endurance athletes. The Physical activity and AF section (page unavailable) reports that another study found a U-shaped relationship, but this paper describes its own finding as J-shaped in a community cohort of women and men. It does not establish a U-shaped relationship specifically in male elite athletes or assess dose as hours of training. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [20] Sciarra, 2022, Managing athletes with palpitations of unknown origin with an external loop recorder: A cohort study, J. Sports Med. Phys. Fitness source
    • cites [21] Schmied, 2013, Atrial fibrillation in athletes and the interplay between exercise and health, Eur. Heart J. source

      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 measured

  • May combine two claims.

    Premisecitation

    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].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [13] Lippi, 2017, Atrial fibrillation in highly trained endurance athletes—Description of a syndrome, Int. J. Cardiol. source
    • cites [50] Pelliccia, 2005, Prevalence and clinical significance of left atrial remodeling in competitive athletes, J. Am. Coll. Cardiol. source

      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 measured

  • May combine two claims.

    Premisecitation

    There is an association between endurance exercise and both bi-atrial and ventricular enlargement.

    “Furthermore, there is an association between endurance exercise and both bi-atrial and ventricular enlargement [52].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [52] Mont, 2009, Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter, Europace source

      The Arrhythmia substrate section reports larger atria in endurance athletes, and the Atrial flutter section suggests right atrial dilatation may result from volume overload. It also reports greater left ventricular mass in patients with atrial fibrillation, but does not establish ventricular enlargement associated with endurance exercise. Page numbers were not available in our copy. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Verapamil, a non-dihydropyridine calcium channel blocker, is a viable option and can sometimes be more effective than beta-blockers in controlling heart rate, especially in athletes who are sensitive to the fatigue or reduced exercise tolerance commonly associated with beta-blockers.

    “Verapamil, a non-dihydropyridine calcium channel blocker, is a viable option and can sometimes be more effective than beta-blockers in controlling heart rate, especially in athletes who are sensitive to the fatigue or reduced exercise tolerance commonly associated with beta-blockers [86].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [86] Koldenhof, 2022, Rate control drugs differ in the prevention of progression of atrial fibrillation, Europace source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the EORP-AF study of 2442 patients with AF, the intensity of physical activity was inversely correlated with the CHA2DS2-VASc score, and the high-intensity exercise training group presented reduced mortality and progression rates to permanent AF compared to groups of mild intensity or no exercise.

    “The intensity of physical activity was inversely correlated with the CHA2DS2-VASc score, indicating that a smaller percentage of patients in the high-intensity group required anticoagulation compared to those in the mild-intensity group, where the percentage of patients receiving anticoagulants was higher [65].”
    • Also stated in: § 4. Clinical Significance, Screening and Management · plain
      “Moreover, the high-intensity exercise training group presented reduced mortality and progression rates to permanent AF compared to groups of mild intensity or no exercise [65].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [65] Proietti, 2017, Self-reported physical activity and major adverse events in patients with atrial fibrillation: A report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry, Europace source

      Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The direct correlation between exercise and a decrease in intra-esophageal pH, as well as acid reflux disease and an increased risk of AF, has been shown in many observational studies in elite athletes.

    “The direct correlation between exercise and a decrease in intra-esophageal pH, as well as acid reflux disease and an increased risk of AF, has been shown in many observational studies in elite athletes [61,62,63,64].”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [61] Collings, 2003, Esophageal reflux in conditioned runners, cyclists, and weightlifters, Med. Sci. Sports Exerc. source
    • cites [62] Soffer, 1993, Effect of graded exercise on esophageal motility and gastroesophageal reflux in trained athletes, Dig. Dis. Sci. source
    • cites [63] Choi, 2001, The role of gastrointestinal endoscopy in long-distance runners with gastrointestinal symptoms, Eur. J. Gastroenterol. Hepatol. source
    • cites [64] Kunz, 2009, Is there a link between gastroesophageal reflux disease and atrial fibrillation?, Clin. Cardiol. source

      The Discussion reports that GERD was associated with a 40% higher risk of atrial fibrillation, and Clinical Investigations continued describes a small study linking decreased intra-esophageal pH to AF onset. Neither passage links exercise to decreased pH or identifies elite athletes as the studied population, so those parts of the attributed claim are unsupported. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Another beneficial effect of exercise is improved cardiomyocyte calcium handling, which contributes to gradual hypertrophy and increased contractility of the myocardium.

    “Another beneficial effect of exercise is improved cardiomyocyte calcium handling, which contributes to gradual hypertrophy and the increased contractility of the myocardium [75].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [75] Kemi, 2010, Mechanisms of exercise-induced improvements in the contractile apparatus of the mammalian myocardium, Acta Physiol. source

      The “Exercise training and intracellular Ca²⁺” section says improved calcium handling chiefly explains exercise-induced changes in cardiomyocyte contractility. The “Cardiomyocyte hypertrophy” section describes a possible pathway from increased calcium cycling to hypertrophy, but calls that mechanism debatable and says it requires more study. Thus the claim states the hypertrophy link more firmly than the source does. Page numbers were not provided in our copy. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the RACE 3 trial, 119 individuals with persistent AF and HF performed moderate intensity cardiac rehabilitation while 126 controls received usual care, and sinus rhythm was present in 75% of patients who performed cardiac rehabilitation versus 63% in patients who received usual care after 1 year of follow-up.

    “In another equally significant study, the RACE 3 trial, 119 individuals with persistent AF and HF performed moderate intensity cardiac rehabilitation while 126 controls with the same background received the usual care. The trial showed that a sinus rhythm was present in 75% of patients who performed cardiac rehabilitation versus 63% in patients who received usual care after 1 year of follow-up [73”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [73] Rienstra, 2018, Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation: Results of the RACE 3 trial, Eur. Heart J. source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Verapamil slows conduction through the AV node without significantly impairing exercise capacity, making it a reasonable choice in selected patients.

    “Verapamil slows conduction through the AV node without significantly impairing exercise capacity, making it a reasonable choice in selected patients.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [86] Koldenhof, 2022, Rate control drugs differ in the prevention of progression of atrial fibrillation, Europace source

      The Discussion (page unavailable) says verapamil lowers heart rate during atrial fibrillation, supporting the rate-control aspect of the claim. It does not identify slowed AV-node conduction as the mechanism or assess exercise capacity. The Discussion’s Limitations also caution that these findings cannot yet be extrapolated to clinical practice, so the recommendation for selected patients is not established by this study. (LLM, conf=0.77)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In studies such as the ARREST-AF cohort study or the ACTIVE-AF trial, regular exercise programs exhibited a reduction in AF-related symptoms, AF incidence, and AF recurrence rates.

    “In studies, such as the ARREST-AF cohort study or the ACTIVE-AF trial, regular exercise programs exhibited a reduction in AF-related symptoms, AF incidence, and AF recurrence rates [76,77].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [76] Pathak, 2014, Aggressive risk factor reduction study for atrial fibrillation and implications for the outcome of ablation: The ARREST-AF cohort study, J. Am. Coll. Cardiol. source

      The intervention description (section labeled CONCLUSIONS; page unavailable) includes prescribed regular exercise as part of a broader risk-factor and weight-management program. The ATRIAL FIBRILLATION results report greater reductions in symptoms and recurrence after ablation in the management group. The study did not isolate exercise’s effect or assess new AF incidence: participants already had symptomatic AF. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [77] Elliott, 2023, An Exercise and Physical Activity Program in Patients with Atrial Fibrillation: The ACTIVE-AF Randomized Controlled Trial, JACC Clin. Electrophysiol. source

  • May combine two claims.

    Premisecitation

    In an observational study of 492 marathon runners, hours of training correlated with LA enlargement, indicating a higher risk of AF in athletes with more hours of exercise training (24% in <1500 h, 40% 1500-4500 h, and 83% in >4500 h).

    “An observational study involving 492 marathon runners reported a correlation between hours of training and LA enlargement, indicating a higher risk of AF in athletes with more hours of exercise training (24% in <1500 h, 40% 1500–4500 h and 83% in >4500 h) [6].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [6] Wilhelm, 2011, Atrial remodeling, autonomic tone, and lifetime training hours in nonelite athletes, Am. J. Cardiol. source

      The Results report that left atrial enlargement increased across training groups: 24%, 40%, and 83%. But 492 runners applied; only 60 entered the analysis, and they included both marathon and nonmarathon runners. The percentages describe left atrial enlargement, not AF risk or incidence, although the Discussion links atrial remodeling to AF. (LLM, conf=0.91)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In a study of 12 veteran male endurance athletes assessed by cardiac MRI, half (6/12) demonstrated late gadolinium enhancement compared to sedentary controls, and years in training and number of competitive marathons predicted prevalence of LGE.

    “Similar findings of myocardial fibrosis were presented a few years later in another study involving 12 veteran male endurance athletes who were assessed by cardiac magnetic resonance imaging (MRI) [54]. Specifically, half of them (6/12 athletes) demonstrated late gadolinium enhancement (LGE) compared to sedentary controls. The number of years spent in training (p < 0.001) and the number of”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [54] Wilson, 2011, Diverse patterns of myocardial fibrosis in lifelong, veteran endurance athletes, J. Appl. Physiol. source

  • May combine two claims.

    Premisecitation

    Physical activity contributes to a decrease in all-cause cardiovascular mortality and ischemic stroke, as shown in the EORP-AF study.

    “Physical activity seems to contribute to a decrease in all-cause cardiovascular mortality and ischemic stroke, as shown in the EORP-AF study [65].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [65] Proietti, 2017, Self-reported physical activity and major adverse events in patients with atrial fibrillation: A report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry, Europace source

      The Methods and Discussion passages examine peripheral arterial disease and cardiovascular-prevention drugs, not physical activity. Searches for physical activity, exercise, and ischemic stroke found no passage linking activity to reduced mortality or stroke in this study. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the HF-ACTION study, 193 individuals with AF and heart failure underwent 36 sessions of supervised exercise followed by a 2-year home-based rehabilitation program, and investigators did not observe any difference in hospitalizations, mortality, events related to AF, or other major outcomes between the training and control group after a median follow-up of 2.6 years.

    “In the HF-ACTION study, 193 individuals with AF and heart failure (HF) initially underwent 36 sessions of supervised exercise, and then continued a 2-year home-based rehabilitation program [72]. Investigators did not observe any difference in the number of hospitalizations, mortality, events related to AF, or other major outcomes between the training and the control group after a median follow-up”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [72] Luo, 2017, Exercise Training in Patients with Chronic Heart Failure and Atrial Fibrillation, J. Am. Coll. Cardiol. source

  • May combine two claims.

    Premisecitation

    Atrial fibrillation can recur due to triggers outside the pulmonary veins, including ectopic activity from the posterior left atrium, superior vena cava, or coronary sinus, or from structural remodeling of the atria unrelated to the pulmonary veins, such as fibrosis, inflammation, or electrical heterogeneity.

    “AF can recur due to triggers outside of these areas, including ectopic activity from the posterior left atrium, superior vena cava, or the coronary sinus, or from other mechanisms of the structural remodeling of the atria, unrelated to the pulmonary veins, such as fibrosis, inflammation, or electrical heterogeneity [91].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [91] Kawai, S., Mukai, Y., Inoue, S., Yakabe, D., Nagaoka, K., Sakamoto, K., Takase, S., Chishaki, A., and Tsutsui, H. (2019). Non-Pulmonary Vein Triggers of Atrial Fibrillation Are Likely to Arise from Low-Voltage Areas in the Left Atrium. Sci. Rep., 22. source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    For comparable training and performance, male athletes showed more pronounced atrial remodeling, a concentric type of ventricular remodeling, and altered diastolic function compared to female athletes.

    “Specifically, Wilhelm et al. enrolled 61 female and 60 male athletes and found that, for a comparable amount of training and performance, male athletes showed more pronounced atrial remodeling, a concentric type of ventricular remodeling, and an altered diastolic function [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Wilhelm, 2011, Gender differences of atrial and ventricular remodeling and autonomic tone in nonelite athletes, Am. J. Cardiol. source

  • May combine two claims.

    Premisecitation

    High consumption of these supplements may lead to an increase in blood pressure by 10 mmHg and an increase in heart rate by 5-7 beats per minute, even in healthy people.

    “Moreover, high consumption of these supplements may lead to both an increase in blood pressure by 10 mmHg and an increase in heart rate by 5–7 beats per minute, even in healthy people [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] Steinke, 2009, Effect of “energy drink” consumption on hemodynamic and electrocardiographic parameters in healthy young adults, Ann. Pharmacother. source

  • May combine two claims.

    Premisecitation

    Non-approved anabolic steroids are used at competitive levels to improve performance and are associated with an increased risk of AF in young athletes.

    “Non-approved anabolic steroids are being used at competitive levels in order to improve performance, and have been associated with an increased risk of AF in young athletes [39,40].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [39] (2024, August 13). Available online: https://www.wada-ama.org/sites/default/files/2022-01/2022list_final_en_0.pdf.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [40] Lau, 2007, Atrial fibrillation and anabolic steroid abuse, Int. J. Cardiol. source

  • May combine two claims.

    Premisecitation

    Athletes present increased arterial blood pressure during exercise and, in combination with atrial wall stretching after long-term strenuous endurance training, may lead to the development of arrhythmogenic areas due to microtrauma, inflammation, and fibrosis.

    “Athletes present increased arterial blood pressure during exercise and in combination with atrial wall stretching after long-term strenuous endurance training, which may lead to the development of arrhythmogenic areas due to microtrauma, inflammation, and fibrosis [13].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Lippi, 2017, Atrial fibrillation in highly trained endurance athletes—Description of a syndrome, Int. J. Cardiol. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The most dominant hypothesis suggests that specific criteria in females, including smaller atria, shorter P-wave duration, differences in autonomic tone, and lower LV mass and wall thickness, may be the keys to differences in AF response between male and female elite athletes.

    “The most dominant hypothesis suggests that specific criteria in females, including smaller atria, shorter P-wave duration, differences in autonomic tone, and lower LV mass and wall thickness, may be the keys to these differences [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Mohanty, 2016, Differential Association of Exercise Intensity with Risk of Atrial Fibrillation in Men and Women: Evidence from a Meta-Analysis, J. Cardiovasc. Electrophysiol. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Physical activity could induce gastroesophageal reflux, and therefore lead to AF.

    “Specifically, physical activity could induce gastroesophageal reflux, and therefore lead to AF [60].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Swanson, 2008, Running, esophageal acid reflux, and atrial fibrillation: A chain of events linked by evidence from separate medical literatures, Med. Hypotheses source

  • May combine two claims.

    Premisecitation

    Despite the negative impact of beta-blockers on athletes' physical performance, they remain a common option among drug therapies.

    “Despite the negative impact of beta-blockers on athletes’ physical performance, they remain a common option among drug therapies [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Pelliccia, 2021, 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease, Eur. Heart J. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Regular exercise can induce chronic systemic inflammation, as shown by increased levels of CRP, and may lead to atrial electrical remodeling and therefore to the development of AF.

    “The proposed theory is that regular exercise can induce chronic systemic inflammation, as shown by increased levels of CRP, and may lead to atrial electrical remodeling and, therefore, to the development of AF [55].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [55] Swanson, 2006, Atrial fibrillation in athletes: Implicit literature-based connections suggest that overtraining and subsequent inflammation may be a contributory mechanism, Med. Hypotheses source

  • May combine two claims.

    Premisecitation

    These athletes may present dynamic fluid alterations which can lead to dehydration, changes in pH, and depletion of electrolytes, including Na, K, and Mg.

    “These athletes may present dynamic fluid alterations which can lead to dehydration, changes in pH, and depletion of electrolytes, including Na, K, and Mg [51].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [51] Turagam, 2015, Atrial Fibrillation in Athletes: Pathophysiology, Clinical Presentation, Evaluation and Management, J. Atr. Fibrillation source

  • May combine two claims.

    Premisecitation

    Years of regular endurance exercise are significantly associated with an increased risk for both AF and atrial flutter, with a 1.16 (95% CI 1.06 to 1.29) times higher risk for AF and a 1.42 (95% CI 1.20 to 1.69) times higher risk for AFl per 10 years of endurance exercise.

    “It was shown that years of regular endurance exercise were significantly associated with an increased risk for both arrhythmias, with a 1.16 (95% confidence interval 1.06 to 1.29) times higher risk for AF and a 1.42 (95% confidence interval 1.20 to 1.69) times higher risk for AFl per 10 years of endurance exercise [8].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Myrstad, 2014, Effect of years of endurance exercise on risk of atrial fibrillation and atrial flutter, Am. J. Cardiol. source

  • May combine two claims.

    Premisecitation

    Most athletes present a lower baseline resting heart rate, which is also a predictor of AF.

    “Moreover, most athletes present a lower baseline resting heart rate, which is also a predictor of AF [49,57].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [49] Baggish, 2015, Mechanisms underlying the cardiac benefits of exercise: Still running in the dark, Trends Cardiovasc. Med. source
    • cites [57] Grimsmo, 2010, High prevalence of atrial fibrillation in long-term endurance cross-country skiers: Echocardiographic findings and possible predictors—A 28–30 years follow-up study, Eur. J. Cardiovasc. Prev. Rehabil. source

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Atrial fibrillation is a complex syndrome in elite athletes with multiple knowledge gaps, including pathophysiological mechanisms such as alterations of the autonomic system, systemic inflammation, and left atrial enlargement and fibrosis.

    “AF is a complex syndrome in elite athletes with multiple knowledge gaps, including pathophysiological mechanisms, such as alterations of autonomic system, systemic inflammation, and LA enlargement and fibrosis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Class III antiarrhythmics, such as sotalol and amiodarone, may be insufficient for control or relatively contraindicated in young athletes, respectively.

    “On the one hand, class III antiarrhythmics, such as sotalol and amiodarone, may be insufficient for control or relatively contraindicated in young athletes, respectively [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Pelliccia, 2021, 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease, Eur. Heart J. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The use of class I antiarrhythmics requires caution due to the potential risk of atrial flutter, but still can be a viable option in well-selected cases-especially in athletes with normal EF.

    “On the other hand, the use of class I antiarrhythmics requires caution due to the potential risk of atrial flutter, but still can be a viable option in well-selected cases—especially in athletes with normal EF.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Pelliccia, 2021, 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease, Eur. Heart J. source

  • May combine two claims.

    Premisecitation

    Digoxin primarily affects resting heart rate by increasing vagal tone and is often less ideal for athletes because it has a minimal impact on controlling heart rate during exertion.

    “On the other hand, digoxin, which primarily affects resting heart rate by increasing vagal tone, is often less ideal for athletes because it has a minimal impact on controlling heart rate during exertion [11].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Pelliccia, 2021, 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease, Eur. Heart J. source

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Premisenone given

    Anticoagulation and rate or rhythm control are cornerstones for atrial fibrillation management.

    “anticoagulation and the rate or rhythm control are cornerstones for AF management”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    It is often difficult to pinpoint specific atrial fibrillation triggers or predict their future behavior.

    “it is often difficult to pinpoint specific triggers or predict their future behavior”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    In the latest ESC and AHA guidelines for atrial fibrillation, physical activity and risk factor optimization are cornerstones for AF management before anticoagulation and rate or rhythm control.

    “in the latest ESC and AHA guidelines in AF, physical activity and risk factor optimization are cornerstones for AF management before anticoagulation and rate or rhythm control”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    The mechanisms driving atrial fibrillation are multifaceted and often not fully understood.

    “the mechanisms driving the arrhythmia are multifaceted and often not fully understood”
    Quote in the paperNot a substantial claim
48 of 48

  • The paper relies on this without support.

    The pathophysiology and underlying mechanisms of AF in elite athletes remain unclear.

    “The pathophysiology and underlying mechanisms of AF in elite athletes still remain unclear.”

  • The paper relies on this without support.

    There are no specific guidelines for elite athletes with AF.

    “there are still no specific guidelines for elite athletes.”

  • The paper relies on this without support.

    Ablation techniques have advanced significantly, leading to higher success rates.

    “Ablation techniques have advanced significantly, leading to higher success rates, especially when carefully selected based on a thorough evaluation of the athlete’s cardiovascular health.”

  • The paper relies on this without support.

    Preparticipation screening plays a crucial role in early detection and management of AF in elite athletes.

    “Preparticipation screening plays a crucial role in the early detection and management of AF in elite athletes who may be asymptomatic, thereby increasing the risk of stroke or other cardiovascular events.”

  • The paper relies on this without support.

    Rate control is often ineffective in relieving symptoms for athletes given their higher baseline vagal tone and increased cardiovascular demands.

    “Through clinical practice, rate control may often be ineffective in relieving symptoms for athletes given their higher baseline vagal tone and increased cardiovascular demands.”

  • The paper relies on this without support.

    There are no specific guidelines of exercise training for elite and non-elite athletes with atrial fibrillation, only some consensus and recommendations.

    “there are no specific guidelines of exercise training for elite and non-elite athletes with AF, but only some consensus and recommendations”

  • The paper relies on this without support.

    There are still no specific guidelines for the management of elite athletes with atrial fibrillation.

    “there are still no specific guidelines for this subgroup”
7 of 7

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Authors
Kourek, C., Briasoulis, A., Tsougos, E., & Paraskevaidis, I.
Affiliations
  • NIMTS Hospital (GR)
  • Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece
  • Hygeia Hospital (GR)
  • National and Kapodistrian University of Athens (GR)
Corresponding author
Paraskevaidis, Ioannis
ORCID
Venue
Journal of Cardiovascular Development and Disease
Publisher
MDPI AG
Published
2024-10-09
Volume
11
Issue
10
Pages
315
ISSN
2308-3425 (ISSN-L)
DOI
10.3390/jcdd11100315
PMC
PMC11508555
OpenAlex
W4403249027
Semantic Scholar
9b6f3df035599c946c69d9e6e553cdf62a0cc4f1
Cited by
7
References
97
Citations by year
2026: 2 · 2025: 5
FWCI
1.90
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Cardiovascular Development and Disease (publishedVersion, cc-by)
  • Preprints.org (acceptedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
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, elite athletes, endurance athletes, exercise training, atrial fibrillation incidence, atrial fibrillation pathophysiology, atrial dilatation, cardiac inflammation, atrial fibrosis, vagal tone, anticoagulation, rate control, rhythm control, risk factors, sex differences

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-12.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-12.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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