Exercise‐induced atrial fibrillation: A case report

KEY CLINICAL MESSAGE: Middle‐aged male athletes, with or without underlying coronary artery disease, exhibiting exercise induced blood pressure (BP) variability and diabetes can have an increased risk of developing atrial fibrillation (AF). Assessment in athletes should include long‐term arrhythmia monitoring. In addition, it is important to exert patients beyond their calculated target heart rate (HR) during an exercise stress test to detect exercise‐induced AF. We suggest this strategy be specifically used for athletes with complaints of intermittent palpitation and chest pain. Referral to an electrophysiologist for a possible ablation procedure should be considered for the management of AF in athletes in whom the use of beta‐blockers may limit exercise tolerance. Bleeding risk with the use of oral anticoagulation needs to be adequately evaluated in athletes with AF who engage in high‐intensity exercise or activities. ABSTRACT: The report highlights the case of a 54‐year‐old Caucasian male (height 5.11′, BMI 29.8) who presented with complaints of chest pain, mild coronary artery disease, palpitation, dizziness, and labile BP with high‐intensity biking exercise. Diagnostic tests (exercise stress test, cardiac catheterization, Holter monitor, and Bardy patch) using standard procedure were unsuccessful at detecting the problem. In a repeat exercise stress test, the patient was exerted beyond the calculated HRmax (up to 117%) when the patient's heart rhythm flipped from sinus rhythm to AF. The patient was referred to a cardiac electrophysiologist and an ablation procedure was performed to prevent exercise‐induced AF with high‐intensity exercise. Young adults, with or without early coronary artery disease, performing high‐intensity endurance exercises may be at risk of developing exercise‐induced AF. This phenomenon is prevalent and well documented in the skiing population and patients with variance in BP during exercise. Endurance athletes tend to have a lower resting HR. As such, the use of standard rate‐control medications in patients with exercise‐induced AF may not be appropriate. Referral to a cardiac electrophysiologist and ablation procedures should be considered in this population for management and symptom control. If tolerated, especially in young adults with complaints of palpitation and chest pain, patients should be exerted beyond their calculated HRmax during an exercise stress test to diagnose an underlying condition of exercise‐induced AF.