Correspondence

Self-Cardioversion of Paroxysmal Lone Atrial Fibrillation with Exercise

N Engl J Med 2002; 347:2085-2086December 19, 2002

Article

To the Editor:

Endurance athletes may be at increased risk for lone atrial fibrillation.1-5 We describe a middle-aged physician athlete with paroxysmal lone atrial fibrillation in whom cardioversion consistently occurs with vigorous exercise.

At 45 years of age, the patient had atrial fibrillation at an average ventricular rate of approximately 55 beats per minute. The results of physician examination, echocardiography, tests of thyroid function, and measurements of electrolytes were normal. After 24 hours of observation, external electrical cardioversion was attempted at progressive energy levels up to 400 J, without success. The patient was discharged home with instructions to take aspirin. The day after discharge, after being in atrial fibrillation for 48 hours, the patient resumed his schedule of normal exercise with a cross-country ski machine. Despite dyspnea with exertion, he achieved a maximal ventricular rate of approximately 170 beats per minute for 20 minutes, at which point he converted to sinus rhythm.

The patient had recurrences of atrial fibrillation at a slow ventricular rate during the following year, all of which were successfully converted to sinus rhythm with exercise. Noninvasive evaluation by an electrophysiologist, including multiple-event recording, resulted in a final diagnosis of paroxysmal atrial fibrillation, most likely a focal atrial fibrillation variant. Its features were not suggestive of vagally mediated atrial fibrillation.

Approximately 30 episodes of atrial fibrillation occurred during the following eight years. The patient successfully terminated all known episodes of atrial fibrillation through exercise, with the use of either a cross-country ski machine or an elliptical trainer. The interval between the onset of atrial fibrillation and the initiation of exercise ranged from approximately 1 hour to 48 hours. The total duration of exercise necessary for cardioversion ranged from approximately 20 minutes to 240 minutes. A ventricular rate of more than 160 beats per minute was achieved before successful cardioversion. Episodes of paroxysmal atrial fibrillation terminated with exercise were recorded with a multiple-event recorder.

Paroxysmal lone atrial fibrillation appears to be more common in endurance athletes than in the general population,1-5 with a reported incidence of approximately 5.3 percent in a selected population of athletes.5 Methods of treatment of atrial fibrillation include ablation, electrical cardioversion, drug-assisted cardioversion, heart-rate control, and anticoagulation. Vigorous exercise may be a noninvasive method of managing atrial fibrillation in athletes.

Mark W. Ragozzino, M.D.
Delaney Radiologists, Wilmington, NC 28403
magresimag@aol.com

James Snyder, M.D.
New Hanover Medical Specialists, Wilmington, NC 28403

Hemal M. Nayak, M.D.
University of Pennsylvania, Philadelphia, PA 19104

5 References

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   Sivertssen E, Benestad AM, Rykke E, Brekke M, Smith G. Er det farlig å drive toppidrett? En 25 års etterundersøkelse av 24 elitelangrennsløpere. Tidsskr Nor Laegeforen 1994;114:3300-3304
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   Link MS, Homoud MK, Wang PJ, Estes NA III. Cardiac arrhythmias in the athlete. Cardiol Rev 2001;9:21-30
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   Karjalainen J, Kujala U, Kaprio J, Sarna S, Viitasalo M. Lone atrial fibrillation in vigorously exercising middle aged men: case-control study. BMJ 1998;316:1784-1785
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Citing Articles (1)

Citing Articles

1. 1

   P. Gates, S. Al-Daher, D. Ridley, A. Black. (2010) Could exercise be a new strategy to revert some patients with atrial fibrillation?. Internal Medicine Journal 40:1, 57-60
   CrossRef