Managing Atrial Fibrillation in the Athlete: Practical Insights Beyond the Guidelines

Purpose of the Review Atrial fibrillation (AF) is increasingly recognized among endurance athletes, but despite growing awareness, athlete-associated AF remains poorly characterized and is often managed using non-specific treatment paradigms. A one-size-fits-all approach is unlikely to adequately address the unique needs of this population. Subsequently, we propose and describe a practical, phenotype-based framework for evaluating and managing AF in athletes. Recent Findings We describe five overlapping mechanistic and clinical - especially the latter two – athlete phenotypes: vagally mediated/trigger-dominant, adrenergic/exercise-triggered, substrate-dominant, older with mixed mechanisms, and competitive/contact sport. Those that are vagally mediated/trigger dominant represent the true endurance athlete and are characterized by paroxysmal yet highly symptomatic episodes with low AF burden that are highly susceptible to pulmonary vein isolation alone. Adrenergic/exercise-triggered athletes may follow traditional teaching and experience symptoms at peak exertion, but these are challenging to manage because of performance limitations with traditional therapies. Substrate-dominant individuals develop profound left atrial remodeling, which evidence suggests increases recurrence risk despite catheter ablation. The older athlete with mixed mechanisms may have conventional AF risk factors that require traditional management in addition to the etiologies above. Lastly, those in competitive/contact sports are defined less by arrhythmia than by the implications of anticoagulation and return-to-play considerations. Summary Athletes represent a distinct and heterogeneous group in which exercise-related triggers, autonomic influences, atrial remodeling, anticoagulation considerations, and performance goals substantially influence disease expression and management. The management of AF in athletes should prioritize not only arrhythmia suppression but also preservation of exercise capacity and athletic identity. This more nuanced understanding of athlete-associated AF will be essential as the population of athletes with AF continues to grow.