Practical guidance for management of atrial fibrillation in sports cardiology

Importance: Atrial fibrillation (AF), the most prevalent sustained arrhythmia, portends higher risk of cardiovascular morbidity and mortality, and is associated with quantifiable impairment in quality of life. While physical activity is widely recognized for its cardiovascular benefits, recent evidence challenges its role in the development of AF. Observations: Emerging data suggest a U-shaped relationship between physical activity and AF risk. Mild to moderate exercise appears protective, whereas prolonged, high-intensity activity is associated with an increased risk, possibly driven by cardiac remodeling, autonomic alterations, and atrial substrate changes typical of the so-called athlete's heart. This relationship is further modulated by other factors, including genetic predisposition, acquired cardiac conditions, and stimulant use. With the growing participation of aging populations in sports, the clinical management of AF in athletes presents unique challenges. Pharmacological strategies for rhythm and rate control may conflict with performance goals, and the use of anticoagulants must be carefully balanced against the risk of traumatic bleeding in contact sports. Recent evidence supports strategies such as short-term anticoagulant withdrawal to mitigate hemorrhagic risk while maintaining thromboembolic protection. A personalized approach, incorporating shared decisionmaking, is essential, particularly for elite athletes. Conclusions and relevance: While regular physical activity generally confers cardiovascular benefits, prolonged intense exercise bouts may paradoxically increase the risk of AF. The evaluation and management of AF in athletes require a tailored, multidisciplinary approach that accounts for the distinct needs of this population.