Acta Cardiologica
ISSN: 0001-5385 (Print) 0373-7934 (Online) Journal homepage: http://www.tandfonline.com/loi/tacd20
The occurrence of atrial fi brillation in former toplevel handball players above the age of 50
Frank Van Buuren, Klaus P. Mellwig, Lothar Faber, Christian Prinz, Andreas
Fruend, Johannes B. Dahm, Tanja Kottmann, Nikola Bogunovic, Dieter
Horstkotte, Thomas Butz & Christoph Langer
To cite this article: Frank Van Buuren, Klaus P. Mellwig, Lothar Faber, Christian Prinz, Andreas
Fruend, Johannes B. Dahm, Tanja Kottmann, Nikola Bogunovic, Dieter Horstkotte, Thomas Butz
& Christoph Langer (2012) The occurrence of atrial fi brillation in former top-level handball players
above the age of 50, Acta Cardiologica, 67:2, 213-220, DOI: 10.1080/AC.67.2.2154212
To link to this article: https://doi.org/10.1080/AC.67.2.2154212
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Acta Cardiol 2012; 67(2): 213-220
213
doi: 10.2143/AC.67.2.2154212
The occurrence of atrial fibrillation in former top-level
handball players above the age of 50
Frank VAN BUUREN1, MD; Klaus P. MELLWIG1, MD; Lothar FABER1, MD, PhD; Christian PRINZ1, MD;
Andreas FRUEND1; Johannes B. DAHM2, MD; Tanja KOTTMANN1, MD; Nikola BOGUNOVIC1,
Dieter HORSTKOTTE1, MD, PhD; Thomas BUTZ1,3, MD; Christoph LANGER1,4, MD
1
Dept. of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Germany; 2Dept. of Cardiology and
Angiology, New Bethlehem Hospital, Goettingen, Germany; 3Dept. of Cardiology and Angiology, Marienhospital Herne, Ruhr University
Bochum, Germany; 4Dept. of Cardiology and Angiology, University Schleswig Holstein, Campus Kiel, Germany.
Objective
Cardiac adaptation to sports activity in endurance athletes is considerably different from that in power athletes. The effects of a highlevel team sport like handball, one of the most popular sports in the world, performed at a younger age, on cardiac rhythm in individuals above the age
of 50 have not been investigated to date.
Methods
Thirty-three former top-level handball players from the first German league (6 former world champions and numerous Olympians)
(57.5 ± 5.5 y) joined our screening programme for former athletes and underwent electrocardiography, echocardiography and spiroergometry. Data were
compared to 24 sedentary healthy controls.
Results Ten of the 33 athletes suffered from atrial fibrillation (AF). Left ventricular diameter was 53.68 ± 4.88 mm in the athletes group and 50.58 ±
4.12 mm in the healthy controls. Analysing the subgroups of handball players (‘AF group’ and ‘non-AF group’), spiroergometry showed oxygen consumption at the anaerobic threshold of 27.54 ± 6.77 ml/kg/min in the AF group and 31.24 ± 10.33 ml/kg/min in the non-AF group (P = 0.228). Absolute left atrial
diameter was 44.34 ± 4.41 mm in the AF group (non-AF group 38.94 ± 3.77 mm, P < 0.001) (healthy controls 37.54 ± 4.34 mm, compared with all athletes
P = 0.015). In all individuals left ventricular wall thickness was within normal limits. However, myocardial walls were thicker in the AF group (11.28 ±
1.83 mm) than in the non-AF group (9.44 ± 1.26 mm, P = 0.002). Athletes in the AF group (187.6 ± 6.42 cm) were significantly taller than in the non-AF
group (180.91 ± 7.31 cm, P = 0.018).
Conclusion
Not only endurance training, but also sports activity with a relevant static component, like team handball, might predispose for AF
above the age of 50. LA size, height and myocardial wall thickness seem to affect the risk of developing AF. More data in non-endurance sports are mandatory to confirm this hypothesis.
Keywords
Endurance training – vagal tone – atrial fibrillation – static component – team sport – handball – athlete’s heart.
INTRODUCTION
It is well documented that regular physical activity
contributes to physical fitness beyond the age of 50 years
due to an optimized arteriovenous oxygen difference
Address for correspondence:
Frank van Buuren, M.D., Heart and Diabetes Center North
Rhine-Westphalia, Dept. of Cardiology, Ruhr University Bochum,
Georgstr. 11, 32545 Bad Oeynhausen, Germany.
E-mail: fvbuuren@hdz-nrw.de
Received 7 September 2011; revision accepted for publication
4 January 2012.
and increases in left ventricular volume, stroke volume
and diastolic filling1. The age-associated decline in maximal aerobic capacity is attenuated in healthy athletes
who continue to engage in habitual exercise compared
with sedentary individuals2. A coexisting atrial fibrillation (AF) impairs this positive effect of sport as it might
be associated with severe and disturbing symptoms
reducing quality of life, as well as increasing mortality3.
Moreover, diabetes, hypertension and ischaemic heart
disease are less frequent among physically active individuals4. However, there is no data showing that AF may
impact on mortality in athletes.
AF is assumed to be the most common tachyarrhythmia in active athletes5. Nevertheless, the prevalence of
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F. van Buuren et al.
this disease in people younger than 25 years in the
general population is very low6. Several years of intense
training in the active phase, particularly in endurance
sport, has been identified as a risk factor for the development of AF in elderly athletes7-9. Some studies have
shown that endurance athletes are at an approximately
five times higher risk of developing AF than those who
are sedentary3,10 and intense training might predispose
to develop bradyarrhythmia11.
The pathophysiology of AF in athletes is poorly
understood and has moved into the focus of clinical
trials12-14. Different mechanisms have been discussed as
reasons for developing AF: (a) a slight dilatation of cardiac cavities due to regular physical activity, (b) an
increased vagal tone with an associated tendency towards
bradycardia13,15, and (c) fibrogenesis16.
Coumel17 described how, in some patients, atrial fibrillation predominantly appeared in a vagal context (e.g. at
night, a few hours after intense exercise or after heavy
meals, etc.). Other reports mainly discuss the relationship
between long-term endurance training and atrial fibrillation18-20. Only scant data are available about former top
level athletes who have not been exclusively involved in
sports with a dynamic component, but also with a moderate to high degree of static elements, like handball21.
The aim of this descriptive study is to provide new
information about the possible influence of professional
moderate and intense static physical activity in combination with dynamic components (handball) at a young
age on the incidence of AF at the age of over 50 years.
METHODS
In our national screening programme for former
athletes we included 33 consecutive former top-level
handball players older than 50 years who joined the
programme on a voluntary basis. All played handball in
the first German league (‘Bundesliga’), including 12
former national players and 6 world champions. Fifteen
athletes had achieved international recognition in the
Olympics. None of them was still active in sports at a
higher level (> 3 hours per week).
Although the total lifetime hours of sport could not
be determined precisely, all athletes described a period
of more than 20 years, with at least 18 hours of sport per
week. The percentage of exclusive endurance training
was about 20% of this time. However, the proportion of
dynamic components during team sport like handball
is also noteworthy. The time after stopping competitive
sports was hard to find out as there were several athletes
who did not quit their sport on a professional level
abruptly. However, 31 of the 33 athletes had terminated
more than 20 years before entering the study.
According to their history of AF, the athletes were
assigned to an AF group (n = 10) or a non–AF group
(n = 23) for subgroup analysis. Data were evaluated
against 24 sedentary healthy age-matched controls who
had not been engaged in sports at a higher level at any
time. They had comparable clinical and anthropometric
characteristics and joined our screening programme on
a voluntary basis.
Apart from the episodes of AF, all 57 individuals
(athletes and controls) were presumed to be healthy.
None suffered from arterial hypertension. Besides the
anamnesis and a physical examination, all individuals
underwent a 12-lead ECG. Height and weight were
measured in underwear and bare feet. Body mass index
(BMI) and body surface area (BSA) were calculated from
these data. Alcohol consumption was queried as a standardized question, quantified by the average daily consumption of alcohol in grams during the past year. More
than 10 grams was the threshold for increased alcohol
consumption. All individuals were below this line.
Systolic and diastolic blood pressures were measured
at rest in a stress-free setting following standardized
methods and, in addition, directly before and during the
physical stress test. The use of drugs at the time of ECG
recording was queried. None of the individuals had
taken cardiac drugs when AF appeared for the first time.
Four of the athletes with AF had the first ECG documentation in another hospital or with their general practitioner. These patients were evaluated in our clinic
within 1 week of first AF manifestation.
Conventional echocardiography was performed
according to the ASE guidelines (GE Vingmed Seven)22.
Left-ventricular end diastolic index (LVEDDi) and leftatrial end systolic diameter index (LAESDi) were calculated by using body surface area (BSA). Measurement
of cavity size and wall thickness was derived from
M-mode recording. Diastolic dysfunction was defined
as an E/A ratio less than 1. Six athletes displayed sinus
rhythm at the time of investigation.
The stress test was performed by spiroergometry
(ZAN 600 USB CPX, h/p/cosmos quasar, Oberthulba,
Germany). At the beginning and in the middle of each
level of the physical stress test, blood pressure and heart
rate were measured. Workload was increased every
2 minutes by 25 Watts, starting at 50 Watts. Workload
was stopped on reaching the anaerobic threshold (AT
VO2) or full exhaustion (peak VO2).
The study was approved by the local ethics committee. It meets international ethical standards and respects
the Declaration of Helsinki23.
The statistical analyses were performed using SPSS
for Windows, version 18.0 (SPSS Inc., U.S.A.). The continuous variables were presented as means and medians,
while standard deviations and quartiles were chosen as
Atrial fibrillation in handball players
measures of dispersion. Regarding their normal distribution, the continuous variables were tested by means of
the Shapiro-Wilk-test.
For the comparison of two independent, normally
distributed samples, the t-test was applied after the
homogeneity of the variances had been tested by means
of the Levene test. Due to the proven homogeneity of
the variances, the Student t-test was carried out. However, for non-normally distributed samples the MannWhitney U test was applied as a non-parametric procedure. A P-value of < 0.05 was assumed as statistically
significant for all statistical tests.
For the diagrams, which were also compiled with SPSS,
box plots were chosen to visualize the medians and quartile distances. While the median, as well as the 25th-75th
percentile, are displayed in the boxes, the t-bars represent
the smallest and largest values. Outliers are considered
values located between 1½ and 3 box lengths outside the
box; they are represented as circles in the diagram.
RESULTS
We studied 57 male individuals (33 former athletes
and 24 healthy controls). Mean age in the athlete group
was 57.55 ± 5.52 years (y) (healthy controls 56.54 ±
5.78 y, P = 0.559). Mean body weight (bw) was 87.33 ±
9.98 kg (82.92 ± 10.28 kg, P = 0.109), mean height was
182.94 ± 7.62 cm (178.96 ± 6.29 cm, P = 0.041).
In all individuals hyperthyroidism was excluded by
TSH laboratory test. None of the participating individuals had an average alcohol consumption of more
than 10 g/day during the last year.
Mean age of the athletes in the non-AF group (n = 23)
was 57.39 ± 5.26 y (AF group (n = 10) 57.90 ± 6.37 y,
P = 0.859). Mean weight was 84.61 ± 8.91 kg (AF group
93.60 ± 9.88 kg, P = 0.015), mean height 180.91 ± 7.31 cm
(AF group 187.60 ± 6.42 cm, P = 0.018). Echocardiography showed that in all individuals (athletes and healthy
controls) systolic function was normal and no structural
heart disease was present.
Ten (30.3%) of the former athletes suffered from AF
(AF group). Six of them displayed sinus rhythm at the
time of examination in our programme, four showed
AF. Seven suffered from paroxysmal AF, three from
persistent AF. Six of the patients in the AF group (others
refused drug therapy) and none of the non-AF group or
the healthy control group were taking beta blockers. The
mean age of AF patients at the time of diagnosis was
53.6 ± 3.13 y. Out of the 10 athletes with AF four had no
symptoms at the time of detecting AF, five had mild
symptoms (EHRA classification II, normal daily activity
not affected), one had severe symptoms (EHRA III) like
palpitations and shortness of breath24.
In the AF subgroup there was a longer PQ interval
(199.17 ± 58.17 sec) in comparison to the non-AF group
(180.36 ± 24.41 sec) (P = 0.414). Other ECG and spiroergometry findings, including blood pressure, are summarized in table 1.
Absolute diameters of LVEDD in the AF subgroup
was 55.33 ± 4.58 mm and in the non-AF subgroup
52.96 ± 4.93 mm (corresponding LA ESD 44.34 ±
4.41 mm and 38.94 ± 3.77 mm). LVEDDi was 25.16 ±
2.59 mm/m2 in the AF group and 25.77 ± 2.47 mm/m2in
the non-AF group (P = 0.524). LAESDi was 20.15 ±
2.17 mm/m2 in the AF group (non-AF group 18.97 ±
2.07 mm/m2) (P = 0.149). In both subgroups diameters
of IVS and PW were within normal limits. Posterior wall
(PW) thickness was significantly higher in the AF group
(11.28 ± 1.83 mm) in comparison to the non-AF group
(9.44 ± 1.26 mm) (figure 1).
In relation to body surface area, the group of athletes
showed a mean LVEDDi of 25.59 ± 2.48 mm/m2, healthy
controls were at 24.86 ± 2.22 mm/m2 (P = 0.258). LAESDi
was 19.33 ± 2.14 mm/m2 (athletes) and 18.63 ± 2.02 mm/m2
(healthy controls, P = 0.219). In both groups wall thickness of the intraventricular septum (IVS) and the PW
was within normal limits (table 2).
Parameters of left ventricular diastolic function were
normal, indicated by an E/A ratio of > 1 in all 53 individuals. Four athletes were excluded from analysis
because they had AF at the time of investigation.
Other echocardiographic parameters are summarized
in table 2.
DISCUSSION
AF is a frequently occurring arrhythmia that demands
further treatment. In population studies the average
prevalence of AF is 0.5% in individuals aged 45-54 years,
about 1% at the age of 55-64 and 4% at the age of 65-74
years8. Several recent studies have confirmed the relationship between endurance training and AF3,8,10,12,14,18-20.
Data on team sports like handball are rare. In the presented study we found a rather high proportion of former top athletes with AF suggesting that atrial arrhythmia could be more common in these individuals.
However, this result should not be overinterpreted as
there is also a relevant endurance training aspect in
handball and the investigated group of athletes is rather
small.
Atrial enlargement and left ventricular hypertrophy,
both features of the endurance athlete’s heart, may
increase the risk of suffering from AF12,14,18. Also, vegetative settings are a suggested reason for AF. Physical activity and increased sympathetic stimuli may act as triggers
for AF in individuals with concomitant predisposing
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F. van Buuren et al.
Table 1 ECG findings, blood pressure and physical performance of athletes and healthy controls, as well as analysis of subgroups (non-AF
group and AF group)
Athletes
(n = 33)
Healthy controls
(n = 24)
Non-AF group
(n = 23)
AF group
(n = 10)
mean ± SD
(median)
mean ± SD
(median)
mean ± SD
(median)
mean ± SD
(median)
57.55 ± 5.52
(58.0)
56.54 ± 5.78
(56.50)
0.559
57.39 ± 5.26
(58.00)
57.90 ± 6.37
(57.50)
0.859
Height (cm)
182.94 ± 7.62
(183.0)
178.96 ± 6.29
(179.0)
0.041
180.91 ± 7.31
(182.0)
187.60 ± 6.42
(186.0)
0.018
Weight (kg)
87.33 ± 9.98
(89.00)
82.92 ± 10.28
(80.00)
0.109
84.64 ± 8.91
(86.00)
93.60 ± 9.88
(94.00)
0.015
BMI (kg/m2)
26.06 ± 2.21
(25.7)
25.87 ± 2.63
(25.8)
0.766
25.84 ± 2.27
(25.21)
26.57 ± 2.08
(26.16)
0.338
Heart rate at rest
(beats/min) a
59.47 ± 9.62
(63.0)
60.04 ± 5.56
(61.0)
0.806
60.91 ± 8.33
(64.0)
PQ interval (ms) b
184.39 ± 33.94
(180.0)
174.04 ± 27.05
(180.0)
0.350
88.78 ± 15.21
(90.0)
77.83 ± 16.15
(70.0)
Systolic blood
pressure at rest
(mmHg) a
126.39 ± 13.83
(126.0)
122.21 ± 10.83
(125.0)
0.223
128.09 ± 15.65
(131.0)
122.50 ± 7.55
(122.5)
0.293
Diastolic blood
pressure at rest
(mmHg) a
80.06 ± 8.13
(80.0)
78.33 ± 7.03
(81.0)
0.406
81.61 ± 8.63
(82.0)
76.50 ± 5.47
(76.0)
0.098
Maximum systolic
blood pressure
(mmHg) a
205.15 ± 28.22
(207.0)
197.17 ± 20.72
(201.0)
0.245
207.13 ± 28.85
(210.0)
200.60 ± 27.63
(196.0)
0.550
Maximum diastolic
blood pressure
(mmHg) a
90.76 ± 13.92
(92.0)
93.17 ± 13.95
(91.5)
0.522
93.48 ± 15.03
(97.0)
84.50 ± 8.63
(82.0)
0.089
AT VO2 (ml/kg bw) a
30.05 ± 9.38
(29.8)
25.72 ± 9.33
(25.1)
0.095
31.24 ± 10.33
(35.6)
27.54 ± 6.77
(29.2)
0.228
Peak VO2 (ml/kg bw) a
36.97 ± 8.14
(37.0)
31.02 ± 8.83
(29.5)
37.91 ± 9.09
(37.5)
35.01 ± 5.58
(34.7)
0.363
Age (y)
QRS duration (ms) b
p value
0.017
0.012
p value
56.3 ± 11.84
(56.0)
0.152
180.36 ± 24.41
(180.0)
199.17 ± 58.17
(197.5)
0.414
90.77 ± 15.11
(92.5)
84.4 ± 15.25
(90.0)
0.232
a
= t-test; b = Mann-Whitney U test, bw = body weight.
AT VO2: oxygen uptake at anaerobic threshold, peak VO2: maximum oxygen uptake.
Table 2 Echocardiographic characteristics of athletes and healthy controls (absolute parameters and indexed by body surface area) as well
as analysis of subgroups (non-AF group and AF group)
a
Athletes
(n = 33)
Healthy controls
(n = 24)
Non-AF group
(n = 23)
AF group
(n = 10)
mean ± SD
(median)
mean ± SD
(median)
mean ± SD
(median)
mean ± SD
(median)
LVEDD (mm) a
53.68 ± 4.88
(54.0)
50.58 ± 4.12
(51.5)
0.015
52.96 ± 4.93
(53.0)
55.33 ± 4.58
(55.0)
0.205
LVEDDi (mm/m2) a
25.59 ± 2.48
(25.7)
24.86 ± 2.22
(24.6)
0.258
25.77 ± 2.47
(26.1)
25.16 ± 2.59
(25.1)
0.524
LAESD (mm) a
40.58 ± 4.65
(41.0)
37.54 ± 4.34
(39.5)
0.015
38.94 ± 3.77
(39.0)
44.34 ± 4.41
(43.5)
0.001
LAESDi (mm/m2) a
19.33 ± 2.14
(19.2)
18.63 ± 2.02
(19.3)
0.219
18.97 ± 2.07
(19.0)
20.15 ± 2.17
(19.7)
0.149
LV IVS ED (mm) b
10.41 ± 1.54
(10.5)
10.38 ± 1.10
(11.0)
0.915
10.08 ± 1.56
(10.3)
11.16 ± 1.27
(11.1)
0.063
LV PW ED (mm) b
10.00 ± 1.66
(10.0)
10.63 ± 0.97
(10.5)
0.071
9.44 ± 1.26
(9.4)
11.28 ± 1.83
(11.2)
0.002
p value
p value
= t-test; b = Mann-Whitney U test.
LVEDD: left ventricular end diastolic diameter, LVEDDi: left ventricular end diastolic diameter index, LAESD: left atrial end systolic diameter, LAESDi: left atrial end
systolic diameter index, LV IVS ED: left ventricle interventricular septum end diastolic, LV PW ED: left ventricular posterior wall end diastolic.
Atrial fibrillation in handball players
a
b
c
d
Fig. 1 Findings in athletes (AF group and non-AF group) for
(a): absolute dimensions of LA (left atrium) and LV (left ventricle) and (b): wall thickness of interventricular septum and posterior wall.
LV EDD = left ventricular end diastolic diameter; LAESD = left atrium end systolic diameter;
LV IVS ED = left ventricle interventricular septum end diastolic diameter; LV PW ED = left ventricle posterior wall end diastolic diameter.
Fig. 2 Peak Vo2 and age.
conditions like hypertension25. On the other hand, due
to an increased parasympathetic activity that accompanies physical conditioning, athletes might have a higher
prevalence for AF, especially at rest26. Most of the arrhythmias in athletes seem to be of vagal origin (57%) since
they occur more commonly during sleep or after heavy
meals, in comparison to 18% in a group of sedentary
controls13. The role of anabolic steroids in the development of AF is largely unknown and still requires further
trials25.
The main aspect of our study is the relationship
between AF and types of sport, according to the Classification of Sports21, with more static components. In
contrast to endurance training, team handball is a sport
with at least a moderate static component. We evaluated
the very special population of 33 former top German
handball players who showed a high prevalence of AF
(30.3%). Although all athletes were screened in our
national programme for top-level handball players, a
selection bias could not be ruled out as we did not see
all former athletes and the individuals suffering from
AF, due to complaints, might be more motivated to have
their heart rhythm checked. Heart rhythm of all individuals has been evaluated on several occasions by
12-lead ECG. We did not apply Holter ECG in the individuals supposed to be free from arrhythmia and so we
cannot comment on potential patients with paroxysmal
AF and no symptoms. The concrete reason for AF in the
presented trial remains debatable because sport-adaptive
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F. van Buuren et al.
cardiac changes could not be ruled out as we did not
apply myocardial biopsy.
Our athletes were evaluated after many years of sport
practice, when some of them had already reduced their
physical training to a rather low level. All individuals
were free from the mentioned co-factors like hyperthyroidism, arterial hypertension and high alcohol consumption.
In athletes, an increased vagal tone might also harbour the risk of developing a first- and second-degree
AV block. Braumann27 states that up to 33% of endurance-trained individuals have a first-degree AV block.
This was supported by our AF group, which showed a
longer PQ time (in comparison to the non-AF group
and the healthy controls). However, this was still within
normal range and not significant (table 1) and for this
reason it could to be of limited relevance. Interestingly,
3 (one of them taking beta blockers) out of 10 individuals in the AF group showed a first-degree AV block,
whereas only 2 out of 23 (9%) did so in the non-AF
group. Athletes also had a longer QRS duration, when
compared with healthy controls, which is in line with
recently published findings in college students28.
Analysing the subgroups, individuals in the AF group
were significantly taller than in the non-AF group
(P = 0.018), which complies with previous studies by
Mont, who found a relationship between height and the
incidence of AF in middle-aged individuals14. In our
study we also found a significant correlation between
weight and AF in the athletes’ subgroups, suggesting that
body dimension influences the tendency to develop AF.
However, these findings could not be confirmed for
BMI.
The data derived from the exercise test did not show
a significant difference between the groups concerning
blood pressure or the level of fitness at the anaerobic
threshold (AT VO2). Hence, AF provoked by concealed
arterial hypertension was unlikely. Healthy controls
showed a lower fitness level. Only peak VO2 differed
significantly (P = 0.012), whereas AT VO2 was not significantly different (table 1, figure 2).
Both LA and LV cavity remodelling observed in
trained athletes represent the physiological consequence
of the global cardiac adaption to increased preload associated with intensive training, a fact mainly seen in
athletes engaged in endurance training26,29-32. Thus, echocardiography is essential to rule out other underlying
diseases (e.g. hypertrophic cardiomyopathy) that might
be responsible for AF.
Especially left atrial remodelling is an additional
physiological adaptation in well-trained individuals
which can be explained by associated LV cavity enlargement and volume overload. Pelliccia published data in
2005 stating that left atrial enlargement defined by a
transverse anteroposterior diameter from the M-mode
of more than 40 mm can be found in about 20% of
active competitive athletes30. In contrast to other
authors, it was postulated that the enlargement is
benign and only rarely associated with AF3,30 as there
were only 0.8% of athletes with enlarged LA diameters
who suffered from paroxysmal AF in the investigated
population.
Analysing the athletes’ subgroups in our study, both
LVEDD (P = 0.205) and LAESD (highly significant,
P = 0.001) were higher in the AF group. However, when
matched with the body surface area, LVEDDi and
LAESDi turned to normal, suggesting a coherency
between absolute dimensions of left atrium and AF.
This has to be interpreted in the light of previous studies. Bjørnstad19 published a study of 30 former top-level
endurance-trained athletes who had not detrained yet
and confirmed studies that maintained physical activity leads to an ongoing enlargement of LA and LV.
Other authors showed a reduction in previously
enlarged heart cavities when training is reduced significantly33.
The hypothesis that the development of an athlete’s
heart is a benign and reversible process after detraining
clashes with the findings in our study because there
seems to be a relationship between AF and intensive
physical activity that is not only focused on endurance
training. Cardiac dimensions of athletes and healthy
controls did not differ when indexed for BSA, raising
the assumption that it is not the size of cardiac chambers
in relationship to body dimensions that makes the difference, but more the structural changes of the myocardium and the absolute dimensions.
Healthy controls showed higher values for left-ventricular PW diameters in comparison to athletes.
Although this finding suggests relatively normal parameters for the individuals engaged in sport during their
youth, the subgroup analysis taught a different lesson.
The AF group showed a significantly thicker posterior
wall in comparison to the other former athletes, strengthening the assumption that an increased hypertrophic
response due to physical activity at a high level might
be associated with a higher tendency to develop AF.
However, enlarged wall thickness was not seen in the
IVS, leaving this point to discussion.
Although these data were collected in a series of
consecutive individuals in our national screening programme for former top-level handball players, we cannot
rule out a selection bias. It has to be taken into account
that the cohort investigated is small because of its very
special focus on top-level handball players. Further case
control and longitudinal studies might further clarify
the relationship between AF and high-level non-endurance sports at a young age.
Atrial fibrillation in handball players
CONCLUSION
It is generally well accepted that regular physical
activity might predispose to develop AF at an older age.
The presented study could show that this finding might
not only be associated with endurance training, but also
with physical activity in the field of handball - a sport
classified as moderately static and highly dynamic.
Hence, our findings are in line with the literature but
need further confirmation through screening more former athletes.
Sports activity at a young age maintains maximum
oxygen consumption at a significantly higher level above
age 50 compared with healthy controls, even though
intense regular physical activity has been terminated.
However, based on this study, we have to consider limits concerning an ‘adequate use’ of sports, despite the
positive effects of regular training on coronary heart
disease and premature cardiac death. Furthermore, in
contrast to some other authors, the data underline the
relevance of height and LA size in athletes with AF.
These findings need further trials to confirm the relevance of ‘non-endurance training’. In addition, the question of possible other cardiac (e.g. modified morphology
of cardiac structures) or non-cardiac (e.g. increased catecholamines due to physical activity) triggers that could
provoke AF should be the focus of future trials.
CONFLICT OF INTEREST: none declared.
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