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5.6.2.2 Prognostic and symptomatic relevance of AF during sports Underlying structural heart disease or pre-excitation should always be excluded before advising sports activity in individuals with recognized AF. It is also important to exclude hyperthyroidism, alcohol abuse, and (illicit) drug use. Intensive sports participation should be temporarily stopped until an identified underlying cause is corrected. Rapid atrioventricular nodal conduction of AF during exercise may lead to symptoms, including dizziness, syncope, fatigue, or impaired physical performance. Therefore, the individual should be instructed to stop PA on the emergence of symptoms and rate control should be optimized. Rapid 1: 1 conduction can occur, especially during atrial tachycardia or atrial flutter (AFL); therefore, if AFL has been documented, prophylactic cavo-tricuspid isthmus ablation should be considered. If there is evidence for adequate rate control while in AF through an exercise stress test or ECG monitoring during training or competition, all sports participation is possible in asymptomatic individuals. Achieving adequate rate control can be difficult, however. Betablockers are the logical choice but may not be tolerated due to their impact on physical performance. Calcium-channel blockers and digitalis are usually not potent enough when used alone. Often a combination of individually titrated negatively chronotropic agents is needed, while avoiding sinus bradycardia at rest or chronotropic incompetence during exercise. Rhythm control is equally complicated. Class III antiarrhythmic drugs are usually insufficient for control (sotalol) or relatively contraindicated in a young population (amiodarone). Although class I drugs may be able to prevent recurrences of AF, they should not be used in monotherapy, since these may increase the propensity to develop AFL (‘class I AFL’), which in the absence of adequate rate control may lead to 1: 1 atrioventricular conduction, high ventricular rates, and very profound intraventricular conduction slowing, with haemodynamic compromise.482,483 Therefore, prophylactic cavo-tricuspid-isthmus ablation should be considered if class I drugs are prescribed in monotherapy in athletes. In patients with sporadic AF, class I drugs may be considered only for acute cardioversion, i.e. as a ‘pill-in-the-pocket’ approach. These patients should refrain from sports as long as AF persists, and until two half-lives of the antiarrhythmic drug have passed.484 Prescription of oral anticoagulants (OAC) depends on the clinical risk profile (mainly CHA2DS2-VASc score).485 Sports with direct bodily contact or prone to trauma should be avoided in patients on OAC.486 Catheter ablation by pulmonary vein isolation (PVI) should be considered if drug therapy fails or as first-line therapy if drug therapy is not desired.487 Several small series have shown that the outcome of PVI in athletes with paroxysmal AF is similar to that in non-athletic patients.488,489

5.6.2.3 Impact of sports continuation on the natural progression of atrial fibrillation after ablation If there are no recurrences of AF within 1 month of a successful ablation procedure, sports activity may be resumed. It is unknown whether continuation of sports after successful PVI might progress the disease process and lead to recurrence of non-pulmonary veindependent AF in the future. Therefore, no firm recommendation can be made about the ‘safe’ dose of sports after ablation. Recommendations for exercise in individuals with atrial fibrillation

Recommendations Classa Levelb

Regular physical activity is recommended to prevent AF.297,470473 I A Evaluation and management of structural heart disease, thyroid dysfunction, alcohol or drug abuse, or other primary causes of AF is recommended before engaging in sports.485 I A Counselling about the effect of long-lasting intense sports participation on (recurrence of) AF is recommended in individuals with AF who exercise vigorously for prolonged periods, especially in middle-aged men.471,475,481,490 I B AF ablation is recommended in exercising individuals with recurrent symptomatic AF, and/ or in those who do not want drug therapy, given its impact on athletic performance.488,489 I B The ventricular rate while exercising with AF should be considered in every exercising individual (by symptoms and/or by ECG monitoring), and titrated rate control should be instituted. IIa C Participation in sports without antiarrhythmic therapy should be considered in individuals without structural heart disease, and in whom AF is well tolerated. IIa C Cavo-tricuspid isthmus ablation should be considered in those with documented flutter who want to engage in intensive exercise, to prevent atrial flutter 1 : 1 atrioventricular conduction. IIa C Prophylactic cavo-tricuspid isthmus ablation to prevent flutter should be considered in individuals with AF who want to engage in intensive exercise and in whom class I drug therapy is initiated. IIa C The use of class I antiarrhythmic drugs as monotherapy, without proof of adequate rate control of AF/AFL during vigorous exercise, is not recommended.482,483 III C After ingestion of pill-in-the-pocket flecainide or propafenone, participation in intensive sports is not recommended until two half-lives of the antiarrhythmic drug have elapsed (i.e. up to 2 days).484 III C Sports with direct bodily contact or prone to trauma are not recommended in exercising individuals with AF who are anticoagulated.485 III A

AF = atrial fibrillation; AFL = atrial flutter; ECG = electrocardiogram. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/42/1/17/5898937 by guest on 07 October 2026