Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter

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Abstract

Introduction

Sports activity has been associated with the development of atrial arrhythmias. Atrial fibrillation (AF) is frequently observed after successful ablation for atrial flutter. Sports activity as a risk factor for AF development after flutter ablation has not been studied.

Methods

We analyzed outcome in 137 patients (83% men) after ablation for isthmus-dependent atrial flutter (excluding patients with concomitant ablation for atrial tachycardia or fibrillation). Sports activity before and after ablation was evaluated by detailed questionnaires. Endurance sports was defined as (semi-)competitive participation in cycling, running or swimming for ≥3 h/week (and for ≥3 years pre-ablation). Median follow-up was 2.5 years. Survival free of AF was evaluated with Kaplan-Meier curves and log-rank statistics. Multivariate analysis was based on Cox proportional hazard evaluation.

Results

Acute ablation success was 99% and flutter recurrence 4.4%. Thirty-one patients (23%) had been regularly engaged in endurance sports before ablation and 19 (14%) continued regular sports activity afterwards. Those performing sports were slightly younger. A history of endurance sports was a significant risk factor for post-ablation AF (univariate HR 1.96 (1.19–3.22), p < 0.01, and multivariate HR 1.81 (1.10–2.98), p = 0.02). Also continuation of endurance sports activity after ablation showed a trend for increased risk to develop AF despite a relatively small sample size (n = 19; multivariate HR 1.68 (0.92–3.06), p = 0.08). Cox proportional hazard calculations revealed a 10% and 11% increased risk for AF development per weekly hour sport performed before and after ablation respectively (p < 0.01 for both).

Conclusion

A history of endurance sports activity is associated with the development of AF after ablation of atrial flutter.

Introduction

Foregoing studies have reported a higher incidence of AF in competitive athletes and in recreational athletes compared to the general population [1], [2], [3], [4]. In patients < 65 years with lone AF, 63% is regularly engaged in sports activity (i.e. > 3 h/week) whereas only 15% of the general population within the same age group is performing similar sports (p < 0.05) [2]. Arrhythmias in athletes are often attributed to underlying heart disease, with sports acting as the trigger, and to the increased vagal tone at rest or the increased sympathetic tone during strenuous exercise [5]. The observed association between AF and sports activity was present despite a lower incidence of other risk factors for AF (like hypertension) and AF is mainly seen in those performing dynamic sports (running, cycling, swimming). This has led to the suggestion that cardiac adaptations like atrial dilatation and hypertrophy, secondary to sports activity, may also contribute to AF development [2].

Ablation for atrial flutter has evolved into a very effective intervention, with a high procedural success rate (90–98%) and low recurrence rate (3–11%) [6], [7], [8], [9]. However, the success of the intervention is often offset by the development of atrial fibrillation (AF), which is observed in as many as 17–60% of the patients during follow-up [6], [10], [11], [12]. There are many recognized risk factors for AF development after flutter ablation, like history of foregoing AF, electrical cardioversion, induction of AF during the ablation procedure, the number of antiarrhythmic drugs used before, left atrial size, mitral regurgitation, left ventricular ejection fraction, structural heart disease and the use of ACE inhibitors, angiotension II receptor antagonists and/or diuretics [6], [10], [12], [13].

We wanted to evaluate whether a history of endurance sports and/or its continuation after flutter ablation is an independent risk factor for AF development. Endurance sports activity has so far not been investigated as a risk factor for AF in this particular patient population.

Section snippets

Patient cohort

We report on 219 consecutive patients who underwent ablation for atrial flutter at the University of Leuven between 1999 and 2002. Sixty-five patients were excluded from analysis because they had concomitant ablation of post-surgical intra-atrial reentrant tachycardia or pulmonary vein isolation for focally-induced atrial fibrillation, leaving a population of 154 patients.

Sports activity was evaluated by detailed questionnaires in which the types of sports, number of years of participation and

Patients and ablation success

One hundred fourteen of the 137 patients were men (83%) with an age of 58 ± 10 years. Of the 50 patients performing regular sports activity before ablation, 31 (62%; 23% of the whole population) were mainly engaged in endurance activities (18 cycling, 11 running, 2 swimming). Clinical characteristics of these 31 patients performing regular endurance sports activity and those who did not are summarized in Table 1. Patients performing endurance sports were significantly more often men, they were

Atrial fibrillation after flutter ablation

Ablation for atrial flutter is a highly effective intervention to prevent its recurrence but many authors have pointed to the development of atrial fibrillation during follow-up [6], [10], [11], [12]. This is not surprising given the fact that both arrhythmias are due to similar structural and electrical modifications in the atrium. Despite effective ablation of atrial flutter (which could lead to some degree of reversed atrial electrical and structrual remodeling) [15], the underlying disease

Acknowledgements

H. Heidbüchel is a Fundamental Clinical Investigator of the Fund for Scientific Research-Flanders.

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