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CW: Treating atrial fibrillation in athletes: Tough choices

The number of emails that come from fellow cyclists (and endurance athletes) with heart rhythm issues amazes me. I am more convinced than ever that our “hobby” predisposes us to electrical issues like atrial fibrillation (AF)—that the science is right.

Obviously, my pedaling “habit” creates an exposure bias. I hear from many of you because we cyclists understand each other. Like you, I consider not competing a lousy treatment option.

As a bike racer, I know things: that prancing on an elliptical trainer at a health club doesn’t cut it, and, that spin classes may look hard, but do not come close to simulating real competition. I know the extent of the inflammation required to close that gap, to avoid getting dropped when one of the local Cancellara-types have you in the gutter in a cross-wind, or the worst one of all, to turn yourself inside out to stay with a group of climbers over the crest of a seemingly endless hill—”ten more pedal strokes and I’m out”…Then ten turns to 20, then 40, and maybe you hang, and maybe not. The common denominator of all this: suffering.

It’s little wonder that we get AF.

With that as a backdrop, my goal for this post is to provide a modest amount of insight to the most common question asked by athletes with AF.

“Should I have an ablation, or not.”

Though my two episodes of heart chaos amount to only a mild case of AF, I think it’s fair to say that personal experience with a problem helps a doctor better understand your choice. I’ve thought to myself, on more than one occasion, what would I do if the watt-sucking irregularity persisted? Would I have an ablation; would I live with it; would I stop drinking so much coffee?

Here’s a stab at highlighting some of the real-world issues that come up frequently when talking with AF-patients in the office:

Intro: Before moving on with any AF-therapy, you should do three things:

  • Make sure that the diagnosis is correct. I frequently see patients incorrectly diagnosed with AF. They are said to have AF, but actually have a focal atrial tachycardia or common atrial flutter. The distinction is important because the latter two problems can be ablated with a simpler and less risky ablation procedure.
  • Stop inflaming your heart with known irritants. I am sorry to tell you this, but alcohol, caffeine, and cold remedies can exacerbate–and in some cases cause–heart rhythm problems. Before taking an AF drug, or having burns made in your left atrium, you should try eliminating mochas, gin and tonics, beer and wine. Got a cold; try my favorite remedy: low-sodium chicken soup. Remember, you are middle-aged now. What was tolerable in your twenties, is no longer such in your fifties.
  • Pay attention to your sleep habits. Disordered sleep is strongly associated with AF. Because skinny people can have sleep apnea you might consider getting a sleep study. At minimum, try improving your sleep hygiene. There are few more potent anti-arrhythmic agents than a good night of sleep.

If these “simple” measures fail, and your confirmed case of AF persists, you have three choices for controlling the heart rhythm. (The below discussion assumes that your heart rate is well-controlled and your blood thinned, if appropriate.)

Option A: Live with AF:

Not treating AF is a choice. I strongly believe in patient-centered medicine. That means, I hear about your symptoms, teach you about the disease, lay out the pros and cons of treatment, and you choose what’s best for you.

For an athletic person without underlying health conditions, AF is not life-threatening. You don’t have to take suppressive drugs, or have a procedure; you could just have AF. And for some, say for example, those with infrequent episodes, minimal symptoms, or those who can accept lower power outputs, foregoing a rhythm-controlling strategy is a viable choice.

An important caveat about declining a rhythm-controlling strategy now, is that later-stages of AF are harder to treat. Many–though not all–cases of intermittent AF progress to persistent or permanent AF. You don’t have to decide on AF-treatment tomorrow, but if you change your mind five years later, restoring regular rhythm becomes a much steeper hill.

The final factor that looms large for patients who accept permanent AF is population data that suggests AF increases the risk of health complications down the road.

Option B: You could take medicine:

In general, for athletes, AF-drugs have significant limitations:

  • At best, they suppress AF only half the time;
  • When they do work, they are often partially effective, decreasing the frequency or duration of episodes;
  • Athletes have low resting heart rates, and nearly all AF-drugs lower heart rate;
  • AF-drugs reduce exercise performance by decreasing either maximal heart rate or the strength of the heart contraction, or both. This truth is a real problem for athletes.

The thing that many doctors don’t know about competitive athletes is that the difference between first and last place in a bike race is razor thin. Those five beats per minute, or twenty watts off the top end produce huge differences in results, and thus, in many cases, self-esteem.

The final point to make about the use of AF-drugs in competitive athletes is one of risk. People talk about the high-risk of AF-ablation, but what is not often mentioned is that studies demonstrating the safety of AF drugs did not include large numbers of “extreme” people like you. We know that smartly-administered AF-drugs in regular people with normal hearts is safe. But is that data generalizable to those of us who close gaps, battle headwinds, and push ourselves to Ironman-like feats? I don’t know for sure, but I wonder whether racing (aka, red-lining) around on drugs that affect the electrical properties of the heart could be called “safer” than ablation?

Option C: You could have an AF-ablation:

The treasure of AF-ablation is eliminating episodes without taking drugs that impair our athleticism. For the afflicted, that’s a big pot of gold.

In people with intermittent AF and normal hearts, AF-ablation equals Pulmonary Vein Isolation. The triggers (or “drivers”) of most cases of early-stage AF arise from the muscle sleeves that wrap the pulmonary (lung) veins. AF-ablation, through point-to point burns, seeks to electrically isolate (“build an electric fence”) around the orifices of these veins. Though an oversimplification, the notion holds that this electric fence keeps the AF from getting to the atrium. The “success” rate of AF-ablation in endurance-athletes is probably the same as the general population–around 70-90%.

AF-ablation in 2011 is much different than it was just a couple of years ago. Approaching AF with a catheter now represents a majority of my procedures. What was once a four hour procedure that sapped you for the day, can now be done in two hours. It is routine to do two ablations in a day. What took sixty minutes of X-ray exposure now rarely exceeds twenty-five minutes.

Here are three reasons for this renaissance in AF-ablation: (there are more)

  • Like many AF-centers, both my own, and our lab’s experience have reached a threshold. AF-ablation has become routine. We have a great team of players. Though it’s not always politically correct to say this: AF-ablation, like much of modern, tech-intensive medicine, is best done by dedicated, specialized personnel.
  • The neural pathways required to perform point-to-point navigation of a catheter in the left atrium have become etched in my brain. The largely human task of feeling the tactile sensations of an ablation catheter in a three dimensional heart chamber took years, and hundreds of cases to learn.
  • GPS technology built into catheter mapping systems—made by medical companies like J&J, and St Jude Medical—succeeded in the rare feat of delivering more than promised. Could I do AF-ablation without expensive mapping systems? Sure I could, but these systems clearly increase the effectiveness and safety of the procedure.

Though AF-ablation has improved greatly, it still could not be called a mickey-mouse procedure. It requires general anesthesia, thousands of dollars of equipment, and a half-dozen specially-trained personnel. It is a shining example of the fury of modern medicine. And there is risk. Major complications include, death, stroke, pulmonary vein blockage, esophageal damage, heart perforation, and blood vessel damage to the legs. The published complication rates are in the range of 2-10%. There’s little doubt that complication rates vary with experience, and that many ablators minimize the risks.

Even when AF-ablation goes well, it’s hard on you. A past AF-ablation patient who happened to be a gifted writer sent me a note describing that his groin areas felt as though they had been stomped on by a guy wearing golf cleats.

The most nagging problem with AF ablation is that AF can come back. Recurrence after a “successful” ablation occurs because the electric fence around the veins isn’t as durable as we would like. More than one in three patients require a second ablation to “spot-weld” leaks in the electric fence—to re-isolate the pulmonary veins. You should hear this fact loud and clear from your AF doctor. We all hope that technology can help us make more lasting lines of electrical block. We need more fury.

Finally, there are many unknowns about the long-term effects and real outcomes of AF-ablation. For the relief of AF-symptoms, we know that ablation crushes medicines. But does it reduce hard outcomes like hospitalizations, stroke rates, and mortality? These are the big questions that ongoing clinical trials (like CABANA) will surely shed light on. In this regard, some early and preliminary data show promise. This look-back (retrospective) study presented at last month’s ACC meeting showed that AF-ablation may reduce the risk of stroke.

Here’s a hunch from years of following AF patients that I have ablated: AF-ablation is going to look better than current-day AF-drugs.


Athletes with AF face a tough choice. The disease tugs at what we hold so precious: our beloved vigor. Each treatment has limitations, risks and benefits. No magic potion exists. No hike to the treasure easy.

I wished you didn’t have to decide.

But…I hope this helps.


20 replies on “CW: Treating atrial fibrillation in athletes: Tough choices”

I would like to read the stats, if known, on success-rate differences between ablations to correct atrial fib, atrial flutter, and SVT. I ask as I’ve just had an ablation for the latter and wondered if the above information specifically applies. Whereas my cycling pal just had a atrial flutter ablation procedure. If there are differences in what we are to expect, well, that would be helpful to know as well. Rick Cheatham

Good question.

I’ve got some images that might help. The short answer is that Aflutter and SVT can be ablated with 99% success and little chance for recurrence. This is not the case for AF. I’ll post more on this soon.

Great read John. As you know I lived with AF and cycling for many years before taking the plunge in to ablation. I had both flutter and affib done at the same time. I rate my success as high as I have had only a couple of blips since my ablation, though I do still have PAC’s occasionally.
The one thing I haven’t done since my ablation is return to full on racing. I have done only one race since my ablation and it was a blast but no others. I always thought if I could count on my heart to beat normally I would race so much more. Don’t get me wrong, I still turn myself inside out on training rides, but haven’t the desire to get out and compete. Maybe that desire will return someday soon but until then I will just enjoy NSR at MHR.

Great article, thank you. To me (for now, anyway), living with an a-fib episode every two or three weeks seems better than the uncertain prospects of an ablation… especially since I’ve learned over time to deal with the episodes better psychologically. I’ve had to cut back on the cycling, but even with an successful ablation — at age 60 — I’m not sure I’d go back to training for centuries. The main takeaway from this is to minimize the stress, caffeine and wine, and try to get more sleep. Take control over the things that you can…

Another great post. I regularly refer a-fibbers to this site as a good start for getting a handle on treatment options. This another example.

@Rick: The studies I have seen show flutter successfully treated at 90-95% via ablation. Obviously, Dr. John’s experience is a bit better than that, which doesn’t surprise me because the studies I found are a few years old. Flutter sometimes co-exists with fib though or fib develops after the flutter is eliminated, so eliminating the flutter doesn’t necessary get you out of the woods with respect to atrial arrhythmias.

Thx MR,

Good points about flutter vs fib.

A good rule to remember is that flutter doesn’t just happen spontaneously, but rather, it “organizes” from fib. Dr Marchlinski’s Penn group published a report that showed 50% of patients who had successful flutter (RAtrial) ablation had AFib during follow-up.

My clinical experience confirms this report.

Hi Vincent-
I wish someone that had had an ablation would have told me what I want to get across to you. Best way to say it? Yep, I’d do it again,… in a heartbeat…. : ). I was freaked out of my hospital gown, being that sort of character, and having gone 63 years with nary a health issue. Well, ok, a fractured greater trochanter (hip) in the ’92 Wilson Century here near Atlanta. But, believe me, I’m left in awe of the experience for multiple reasons. In fact, I’d PAY to sit in on an ablation as an observer. I hate to hear that you’re cutting back on the cycling. In my case I couldn’t tolerate the diminished output on the bike having SVT,especially on the longer climbs.
Distilled down, we all have to decide what our cycling means. But you can feel free to call me if you’d care to get details of what to expect should you elect to move forward.
So worth it, Vincent. Just let me know and I’ll send you my phone number. Enjoy The Ride. Rick Cheatham

@Mike – I had ablation for both flutter and atrial fibrillation done at the same time. The odd ting is that the flutter had never shown up during any testing or monitoring. It finally showed its face 2 weeks prior to surgery during pre-op testing.

What a huge relief to read this post Dr. John. My hubs of barely 3 years has been reffing soccer (Manchester United fan) and wrestling matches for over 20 years. That’s 3-5 matches/day during sweltering summer days and lots of road time for the soccer. At 55, he had his first a’flutter’. He mentioned feeling fluttering in his chest a few times climbing stairs during his annual NASA physical and that dr sent him straight to hospital to get a cardiac workup started….which led to echo, stress test, cath, INR checks until the TEE cardioconversion. Immediately successful and he’s able to take multiple cardio meds with no side effects to my amazement! He lucked into getting a new cardio fresh from a Fellowship w 2000 caths already under his belt too. I guess I’m concerned about my guy going into SCA on a soccer field now because my friend’s husband dropped of SCA,43, on a jogging track not long after his Hawaii’ Ironman and he was also an a-flutter guy. Will share this post with my husband and let him call the shots. He isn’t competing but he’s often center ref so must keep up and do some fancy footwork in Tidewater heat.

Great post. Excellent presentation of facts. Even recreational riders suffer from the effects of the rate control drugs. I remember struggling up a hill last May in CA with my heart rate pegged at 148 and my legs begging for more oxygen. It was just awful. I’m 8 months out from ablation for flutter, and I am a happy camper.

Thanks Dr. John. I wish I’d seen this blog in 2008. That’s when I was diagnosed with lone paroxysmal A-Fib and A-Flutter and advised by my primary care physician to stop cycling. I went cold turkey and hardly even dared to walk up stairs. I’d been cycling since 1971 and, while off the bike, missed the camaraderie of my Saturday morning cycling group, the sense of accomplishment after a good ride, and the endorphin rush.

A local EP thought I was a good ablation candidate, so I researched this option and quickly decided to go this route. After three months off the bike, but before the ablation, I reunited with my trusty steed (a lovely Colnago). At that point, I was on flecainide, which did horrible things to my cycling. You and other cyclists can probably understand how depressing it was to be passed by a “girlie-girl” rider in a halter top while trying to climb a short 4% grade. Yup, that was my life. I looked forward to the ablation and getting off anti-arrhythmics.

Although I had several significant side effects from my first ablation, I always knew that if A-Fib returned, I would request a touch-up to avoid being on arrhythmia meds long-term. I attribute much of my approach to being a cyclist: we are goal-oriented and do not do things half-way. Last September, a different EP performed a touch-up ablation and, fortunately, this time, I was not put back on anti-arrhythmic medication.

I still experience SOB and reduced cardiac output and was told a few days ago these could be due to a scarred pericardium from the first ablation and, if so, are permanent. I haven’t given-up on trying to improve my riding. However, I think my “speedy” cycling days are probably over (though I will forever refuse to ride a recumbent!).

In Option C, you refer to GPS technology in the mapping system. Are satellites involved in the navigation of the catheters? I think it is really electromagnetic mapping and you are spoofing us. eh?


Thanks for writing…

You would be correct, ‘electroanatomic’ would be more precise, but I labor to keep pedantic medical terminology to a minimum. For the purposes of understanding the big picture, I think visualizing these systems as GPS-like works.

Does this information about increased risk in cyclists apply to runners as well? Is there any info about this accessible to those of us without medical training?

Gosh, since I read this CW post I feel like I’ve been looking in the mirror and seeing a person who is living in denial. The fact is I have done everything possible to try and get Afib. Although my diet and exercise history has been excellent, I drink too much, lose sleep stressing about random stuff, use caffene for enjoyment and race warm up and more… It seems silly to assume that modern medicine could bail me out if I don’t get a handle on the risk factors that I control. Looks like race season is going to have a whole different meaning this year.

Really neat post, Steve. Of course you certainly could get that handle on those risk factors as a worthwhile project. But, modern medicine will continue to advance in any case. So even if you’ve stacked the deck in your favor with improved habits, and something medical comes up, you’ll be all the better situated for a benefits shower with a little passing of time. But you really don’t want a fib. You want to race. Right now I’m re-training (post-procedure) my body but I know there’s work to do elsewhere. But I’m on it!!! Rick Cheatham

You might be right, I did the group ride last night and stayed in the 150-160 range for about an hour and then started seeing numbers in the 230’s. It was time to say good bye to the group and limp home. Took my meds and my HR dropped down to normal in a few hours, although I feel more tired than normal today. Probably best to seek treatment before I lose my years of base trainning.
Thanks for the insight.

Bear with me here, Steve. My prior syptoms (thankfully) are being recollected so vividly since my procedure was just in March. I’d ride with the Wed. and Sat. rides and see very high pulse readouts even on the 2 mile flat roll outs we do. I thought it was anxiety. Then I sent the computer back to the manufacturer for checking,…but it was ok. Then I had all the cardio testing done (5.5 hours worth). WE saw130 bpm on the inclined treadmill stay put for a bit. Then upward readings many beats at a time up to about 205. The conversion back to 130-quite abrupt- took six minutes. You’ve got the right idea I think regarding treatment. Your doctors will nail down exactly what needs to be done. You’re on the right track. And you’ll be so glad to have the uncertainty behind you.

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