If you have been diagnosed with afib, is it worth training for multisport endurance competition, such as triathlon? This post, prompted by a reader diagnosed with afib, contains valuable advice from a cardiologist whose father is an ultramarathon runner.
Disclaimer
What is Afib?
Cardiologist Dr. Brian Saluck, Citrus Cardiology Consultants, P.A. describes atrial fibrillation (AF), or afib, as “a rapid heartbeat which is irregularly irregular. This means that the duration from beat to beat is different and the rhythm of the heart is not regular.”
He also noted three categories of AF:
- Rapid AF, for which the heart rate is above 110 beats per minute (bpm).
- Controlled AF for which the heart rate is between 60 and 110 bpm.
- Slow afib for which the heart rate under 60 bpm.
The irregular-irregularity common to all types makes afib a condition to be taken seriously. According to StopAfib.org, “If you have non-valvular afib, you are nearly five times more likely than someone without the condition to have a stroke; if you have valvular afib, your risk is 17 times higher. In fact, about 15% or more of all strokes in the US are related to afib. You also have twice the risk of dementia, three times the risk of heart failure, and a 40 to 90 percent increased risk of death compared with people your age who don’t have afib.”
What Are Risk Factors For Afib?
Several factors contribute to the risk of stroke or heart failure in patients with non-valvular atrial fibrillation (AF). These include the patient’s history with diabetes, hypertension, congestive heart failure, valve disease, and prior stroke or transient ischemic attack. Other factors include age, gender, and if the patient has sleep apnea.
Medical professionals often assign a number to each of the primary risk factors to arrive at a score called CHA2DS2-VASc. The risk score is used to define a treatment plan, including prescription of medications such as anti-coagulants.
Is endurance exercise a risk factor for producing an Afib event?
Is there such a thing as exercise-induced AF? “Yes, for some people, exercise can be a risk factor, ” according to Dr. Saluck.
“There is a thought that in athletes whose resting heart rate is too slow, exercise can induce an afib. A normal heartbeat, over 50 bpm, suppresses other irregular heart beats. However, if the sinus heart beat, that originating from the sinus node of the heart, is low, the irregular heartbeats can take over.”
Planning To Start Triathlon But Have Afib?
“The potential risk of exercising with AF is heart failure, ” stated Dr. Saluck. “As you demand more oxygen to the heart, the heart is not relaxing normally. When you are in afib, you lose the atrial kick that normally occurs when the top part of the heart, called the atrium, contracts during the peak filling of the ventricle. That extra little contraction improves the cardiac output by 15 to 20%.
“When you are not in a normal rhythm, that is in afib, you do not have the normal contraction of the sinus node. When the atrium does not contract, you lose the extra 15 to 20% efficiency. A person with afib can go into heart failure because of this.”
A person diagnosed with afib should check with their doctor before beginning triathlon training.
According to Dr. Saluck, “a patient with afib who is considering triathlon should have an electrocardiogram (EKG or ECG) and an echocardiogram, which is a sound wave picture of the heart. These will ensure that the structure of the heart is intact and that there are no valve problems with the heart which can cause the afib, such as a mitral valve regurgitation or aortic valve narrowing (stenosis), something older adults are more likely to exhibit.”
“A lot of times, afib is a marker for underlying ischemia or decreased blood flow to a heart artery. So, if the patient has risk factors in the family and has afib, I might want to do an exercise stress test by putting the patient on a treadmill to see how their endurance is and what their heart rhythm response is to exercise.”
“We also want to make sure their electrolyte levels are okay and check their thyroid to make sure it is not off.”
Depending on the patient, their initial results, and their history with endurance sports, including the distances and duration of the events, these tests may be repeated yearly or less frequently. “If everything with the initial tests is normal, the patient is probably good for five years.”
Managing Afib While Training For And Competing In Triathlon
Plenty of men and women diagnosed with AF take part in endurance sports, such as triathlon. Applying the advice of their primary physician or cardiologist means they can derive the benefits of exercise while minimizing the risks associated with the condition. Here is an approach for managing these risks.
Be Aware of Afib Related Signs and Triggers
While training or racing, listen to and look at your body for signs of AF. For example, are you feeling shortness of breath? Do you feel fatigued? Are legs becoming swollen? These could be warning signs of heart failure.
Not all the sports of triathlon may pose equal risk. A May 2023 publication in Clinical Journal of Sports Medicine reported an association between swimming and AF. In their paper titled AFLETES Study (Atrial Fibrillation in Veteran Athletes and the Risk of Stroke), authors Pallikadavath et. al. wrote, “This is the first study to demonstrate that swimming was associated with an increased risk of AF when compared with other sports and after adjusting for lifetime exercise dose.”
According to Dr. Saluck, this finding may be consistent with the ‘divers reflex’ phenomenon. The ‘divers reflex’, or mammalian diving reflex, is a common response of all mammals to entering cold water. One result is a drop in heart rate. This happens when, with swimming, a person first enters cold water. If the heart rate is already low, as is likely for trained athletes, the irregular heartbeats can take over.
While training, pay attention to your body and learn its response to the unique stress from each of the sports.
Monitor Heart Rate and Heart Rate Signature
According to ActiveCor, maker of KardiaMobile ECG sensor, “Pushing too hard is the number one reason why exercise may become unsafe for someone with atrial fibrillation.”
Technology for monitoring heart rate has been available for many years and is even more widely accessible today.
According to Dr. Saluck, pay attention to how rapidly your heart rate rises at the beginning of exercise and how quickly it comes down after exercise. Normally, heart rate should rise slowly over three to five minutes. Once exercise has ended, it should drop considerably over one to two minutes.
Recently, companies including Apple, Samsung, Fitbit, and Garmin have come out with wearable devices having an FDA cleared ECG (electrocardiogram) function. While not a watch or wearable device, ActiveCor’s KardiaMobile is a small sensor device that connects to your smartphone to record an ECG.
Start Hydrated and Stay Hydrated
Hydration level is critical to heart function and a common thread in many of AF triggers. As we become dehydrated, our heart rate naturally increases. Dehydration also contributes to an imbalance in electrolytes, particularly magnesium and potassium.
There is also a high association between alcohol and AF, especially for those who drink more than mildly. In addition to weakening the heart muscle, alcohol is also a powerful diuretic, contributing to dehydration.
Restful Sleep
Sleep apnea not only affects the quality of sleep but can also increase AF events. “As we age, we lose muscle tone. This can extend to the muscles in the throat, increasing the risk of sleep apnea,” says Dr. Saluck.
Manage Anxiety
“Mental stress and anxiety definitely increase your risk for heart rhythm disturbances. Anxiety in particular can change the hormonal receptors of the heart.”
‘Broken heart syndrome‘ is a stress-related phenomenon which can also cause AF. Sudden acute but stressful events, such as loss of a loved one, being in a car accident, or dealing with financial problems may trigger ‘broken heart syndrome’.
Stress, whether physical, mental, or emotional, must be managed for us to perform at our peak athletically as well as to control AF.
Conclusion – Can I Do A Triathlon With Afib?
A diagnosis of AF does not automatically mean a person cannot begin or continue with multisport endurance activities like triathlon, duathlon, or aquabike. However, it is important to involve your doctor and/or a cardiologist in the initial and ongoing discussion.
Cardiologist Dr. Brian Saluck offers a few key recommendations. First, hydrate well before starting and then stay hydrated with electrolytes throughout the training session or race. He also recommends wearing a heart rate monitor to make sure their heart rate does not go too high outside its normal range. If your heart rate goes high or you don’t feel normal, take a break.
Acknowledgements
Thank you to Dr. Brian Saluck, Citrus Cardiology Consultants, P.A. for contributing to and reviewing this post.
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