Atrial Fibrillation in Athletes - Unique Challenges in Diagnosis and Management

Join our special guests, Drs. Auroa Badin and Bradley Lander, as we discuss the case of an elite professional athlete found to have atrial fibrillation. We discuss the challenges regarding anticoagulation, medical therapy, and the role of monitoring for burden of arrhythmia in these patients. Finally we review the role of definitive ablation, including the shared decision making process.

For more information:
HRS expert consensus statement on arrhythmias in the athlete

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Transcript

Kanny: 0:10

So welcome everyone back to the Cardio Ohio podcast. This is Kenny Graywall past president of the Ohio chapter of the ACC here in Columbus, Ohio. Really excited to introduce a new co host. I'd like everyone to welcome Dr. Ali Azeem, who's clocking in from Cleveland, Ohio. Ali, do you mind just introducing yourself and talking a little bit about your current position? Thanks

Ali: 0:36

Sure thing. Thanks so much. Can I really appreciate the opportunity? My name is Ali Azeem. I'm a first year cardiac electrophysiology fellow here at University Hospitals in Cleveland. I grew up in Northeast Ohio, Youngstown, Ohio, went to Case Western here in Cleveland for school before going to Tufts for medical school, UPMC for residency, and then coming back here to Cleveland for general cardiology fellowship, where I was a chief fellow and stayed on for just starting clinic. electrophysiology fellowship just this July. And happy to introduce Brad Lander. Brad Lander was just recruited also to university hospitals here in Cleveland last year to direct our sports cardiology program.

Brad: 1:20

Yes, it's thanks for the introduction. I, I'm originally from Cleveland. I went to a case for medical school and then actually was first exposed to sports cardiology as a resident at Mass General. They had a very, and they still do have a very large and well run program called the cardiovascular performance program. At that time, it was led by Dr. Aaron Baggish and Dr. Megan Wosfy, and, you know, essentially, they've trained a new generation of sports cardiologists and after that, I went to Columbia for my general cardiology fellowship, and I had the chance to work with Dr. Dave Engel, who is another sports cardiologist and echocardiographer who Is one of the main cardiologists for the NBA and, you know, after that I did an extra year of advanced echo training at Columbia and did an advanced fellowship in sports cardiology and hypertrophic cardiomyopathy. with Matt Martinez at Morristown Medical Center. And then here I am back in Cleveland you know, leading the sports cardiology center and helping to build the HCM program as well.

Kanny: 2:30

Thanks, Brad. I'm really curious about the fellowship you did with Dr. Martinez. I know he's one of the giants in sports cardiology. Is that a new trend to have advanced training like that available? I'm just asking on behalf of some of our fellows who, may have an interest in that career pathway.

Brad: 2:47

Absolutely. You know, it's it's an ongoing discussion within the sports cardiology community and honestly, the HCM community is how do we train you know, experienced providers who can handle and you know, treat the nuances of, of these patients. And so Dr. Martinez has a fellowship, you know, essentially one or two fellows per year, and you train in both HCM and sports cardiology. That's essentially all that he sees. So it's high volume. There is some imaging training as well, predominantly cardiac MRI, and he's actively recruiting for, for next year's fellow. So it's a fantastic experience. Excellent. And Dr. Martinez is a tremendous mentor as well.

Kanny: 3:37

Oh, that's great. I'd like to introduce our second guest as well. It's my colleague from here in Central Ohio, Dr. Arwa Badeen. He's currently an electrophysiologist here at Ohio Health, but he has a lot of ties to Central Ohio, having also done his fellowship in medicine. At Ohio State University, Aroah welcome and just let our audience know a little bit about your pathway that led you to your current position and interests.

Auroa: 4:08

Thank you, Kenny, Ali, and great to talk to you I'm originally from Syria. I did some training in New York and New Jersey. I did a non accredited heart failure after my residency at Mount Sinai and then did my cardiology fellowship at University of Illinois. I trained like you mentioned at OSU for cardiac electrophysiology and I had some exposure there specifically for arrhythmia and athletes. I was a faculty at University of Texas, San Antonio, and we had exposure to anywhere from basketball players to football players there. I joined this practice here at Ohio health Columbus. Three years ago And so happy to be here.

Kanny: 5:05

Yeah, well, thank, welcome, welcome both of you. So we're going to spend the next 25 or 30 minutes just talking about atrial fibrillation in athletes, hopefully talk about it both in recreational and elite athletes, but also if we have time, masters athletes, which is really a growing population and, of interest in sports cardiology. So, Aro, I actually wanted to talk, talk just by briefly summarizing that case you mentioned because I think it's a really interesting patient and I think it's really what kind of led me to be to really want to get more information about this condition. So this patient is a an athlete in his mid twenties. He's an elite professional athlete. I'm not going to say his sport or, where he performs just for the sake of their privacy. But. As part of a routine athletic screening prior to his season an EKG just completely incidentally showed he was in atrial fibrillation with a controlled rate at about 60. Now, he had no real relevant past history. He was not using any performing enhancing drugs, minimal, risk factors for AF in terms of caffeine use, alcohol use. His screening included an echocardiogram, which was completely normal. And once again, this is a routine screening done by his athletic association. So, he really initially reported no symptoms at all, but on further questioning did admit he, for quite a period of time, had had episodic palpitations, but they were not really bothersome or interfering, with either his training or his competition. He really had not been having any limitations with his workouts, either in practice or in competition. So I got Dr. Badin involved and, we did recommend to the patient that we, we start by getting a cardioversion done, at least getting back to sinus rhythm. We did some imaging of his left atrial appendage and then he had successful cardioversion, but of course that also meant he had to stay on anticoagulation for a period of weeks, which kind of delayed. His competition. So I'm going to just leave it there while we talk a little bit more about the condition in general and then I wanted to be able to come back to towards the end of our discussion to talk a little bit about some of the decisions we made. in terms of his eventual management. So Brad, I wanted to start just by kind of defining the condition of AFib in athletes. I think it's been kind of a perception in general cardiology that elite level athletes or high level athletes are more prone to atrial fibrillation. Is that really the case in the sports cardiology literature? And, and what do we understand about the epidemiology and risk factors for AF in this group of patients?

Brad: 8:05

Well, that's a, it's a great question and it's a really good representative case. oftentimes what we think of as simple or straightforward decisions for atrial fibrillation in the general population become, you know, much more nuanced and, you know, can be nerve wracking in elite or professional athletes where their livelihood depends on Not, not being on anticoagulation and being able to perform at their best. But yes, there is a significant amount of literature about atrial fibrillation and athletes, and it's mostly a specific population. Oftentimes, I'll get questions of Is there such a thing as too much exercise or, or can there be, you know, an overuse injury for the heart? And, really, by and large, exercise is very good for the heart, for mortality for risk factors, but AFib is one of the few conditions where it is more prevalent in a certain segment of the population. And that is predominantly in older, and when I say older, I mean, you know, 50s, 60s, 70s masters athletes, predominantly endurance athletes, like running, cycling. Cross country skiing who have been exercising for, a long time at high levels, it is more rare to have the case like you're describing, or it's probably a younger, younger athlete in in a sport. That's not one of these three that I mentioned. But it's been estimated that the risk of a fib and these high intensity athletes is, you know, anywhere from 2 to 10 times as high compared to sedentary individuals. And, you know, one of the best studies that looked at this phenomenon was published about about 10 years ago at this point, and looked at approximately 52, 53, 000 athletes who are competing in the Vasa Opa, which is a long distance skiing event in Sweden. And they found that the strongest predictors of AFib were the number of races completed and race times. So, the more you raced, and the faster your race time. The, the more likely you were to be diagnosed with, with atrial fibrillation. And since then there have been other meta analyses that have been published that look at similar, similar questions and confirm that it's really a significantly higher risk of AFib in these older masters endurance athletes. as compared to sedentary individuals.

Kanny: 10:47

Brad, do you think some of the traditional risk factors still apply in this population? You know, hypertension sleep apnea caffeine use, et cetera.

Brad: 10:58

Absolutely. Definitely. And whenever I see an athlete like this we don't start the conversation with necessarily talking about their, their athletic history. We general terms of of risk factors for atrial fibrillation. I asked them about supplement use, I asked them about alcohol intake, I asked them about sleep apnea, I asked them about hypertension, I asked them about family history and for some of these athletes, they take supplements or pills that I've never even heard of and so I kind of transitioned the way I asked the question to be from, what medicines do you take to what do you put in your body?

Auroa: 11:46

I'd like to mention something about caffeine because it was brought up twice Kenny. You know, I, I'm a big advocate of coffee and I do think there's actually a, a cardioprotective effect of caffeine and The athletes are not shunted from or shunned from that effect coffee and arrhythmia is this is a very large designated myths regarding caffeine and, and certain arrhythmias, specifically atrial arrhythmias. When you look at studies that looked specifically at actually quantitative numbers of P. A. C. S. Or extra systoles in the crave trial and others. There was no associated increase. And part of the reason is, I think, some of the mechanisms that caffeine actually might be protective from a fib, believe it or not. in in the population. But I, I agree with with Brad when it comes to you know, other supplements A lot of this is not getting scrutinized by the FDA because they have a special category and it's sometimes added to the energy drinks that some of those athletes may consume. And potentially there's a lot of case reports and a total evidence that this might lead to increase in potentially AFib and other arrhythmias in this population.

Ali: 13:24

Thank you. That was really helpful. Just to go a little bit deeper on that topic about the mechanisms of atrial fibrillation could you two talk a little bit more about the mechanisms of atrial fibrillation the role of atrial fibrosis or volume loading, and how these patients are being treated? Similar, but also different from the general population with AFib.

Auroa: 13:53

Certainly, it is accepted in the, in the athlete population that some of the common you know, multi head phenomenal that leads to a fib. Also applies to athletes. I'm talking more specifically about you know, like the, the tri triangle of having you know remodeling, having triggers. We often in electrophysiology talk about triggers for atrial fibrillation and then potentially the you know, aggressive autonomic system regulation that happens in these athletes. How does that apply to the f. athletes. Well, the electrical and structural remodeling think about fibrosis and validation of the L. A. Which potentially can also affect the action potential duration. So when you're subjecting the cells to an aggressive stimulation during those endurance exercises, And then you have these periods of rest. You have a very high up regulation of the parasympathetic system. And we study in basic EP that, you know parasympathetic system decreases or shortens the action potential duration of the LA. And so if you get any trigger, like an ectopy that may come from the initiation of an exercise or stopping an exercise and having a big gulp of water that signal will likely to lead to this micro reentrance in the atrium and lead to a sustained episode of AFib. At least that's in theory. And, and people suggested that it seems that the LA dilates more if you have someone who's putting out an output close to 30 liters a minute, which is quite significant comparing to the normal cutting output of five to eight. And so what does dilatation lead to potentially so we're going back to the triggers. That's could be the initiation of an exercise. It could be a small glass of wine after. a competition. It could be any of those. And then you have the right predisposition and you can go into this AFib episodes.

Brad: 16:24

A few things that I would add are within the sports cardiology realm, we tend to think of sports, you know, along a spectrum of, of dynamic exercise and static exercise. And dynamic being, you know, running, cycling, rowing, and, you know, static being more powerlifting, American football sprinting, et cetera. Part of the reason why we've seen the association between endurance exercise or high intensity exercise in long term athletes is because those individuals, that type of sport, the endurance or dynamic sports, those tend to cause more chamber dilation, specifically atrial dilation. And so the atrial dilation, the fibrosis like you're mentioning, and the remodeling all have been postulated to contribute to the increase in AFib in that population. I will say, I'm not sure that there's one specific reason for AFib in this group. It's likely multifactorial like you mentioned. But one, you know, kind of pearl that I would put out there is if it's not a typical a fib plus athlete scenario, you know, 60 year old long term cyclist, it's a younger person. Like the one you're mentioning. I'm always a little bit suspicious that there's something else going on looking for accessory pathways. Well, Parkinson white looking for structural issues. You know, either hypertrophic cardiomyopathy, ARVD, either current or, you know, prior myocarditis. Imaging is really important with echo and cardiac MRI.

Kanny: 18:06

Yeah. Thanks, Brad. Thanks for pointing out the role of imaging. I'm glad you touched on that. Just to follow up on a couple of quick things before we turn our attention to management for the second half of our talk Brad when you do see AF and more of a master's athlete, like you mentioned, like the kind of lifetime endurance athlete, is there any, do we have any evidence that detraining or Exercise abstinence would be part of the management given that, you know, the thought is that, you know, accumulative exercise could be playing a role. And then the follow up to that, very briefly, is, are we aware of any sex differences in the incidence of AF in athletes? Because I know a lot of the studies have historically been done on male athletes.

Brad: 18:54

Those are really important questions. I'll, maybe I'll start with the latter ones. In terms of sex differences. It seems as though the risk of AFib, at least in endurance athletes, is significantly greater in men compared with women. There is a, I guess you could call it, U shaped curve with respect to the risk of AFib in athletes where no, no exercise at all puts you at risk for AFib. And a lot of High intensity endurance exercise over many, many years puts you at increased risk for aphid but more moderate exercise over a shorter period of time is actually protective, as opposed to what you see in women, or what has been reported in women, is that actually there doesn't seem to be quite the same relationship in that the more women exercise, even at higher intensities, or for longer periods of time, their risk of aphid seems to continue to go down. Whether that gives us a hypothesis as to whether any of this is related to hormones or simply because in general, women tend to have smaller atria, shorter P wave durations lower LV mass and wall thicknesses, or whether there's even differences in autonomic tone, there is a difference both in the literature and from what I see in the clinic between, between men and women. And then with respect to, detraining or threshold. It's tough to put a number on threshold for, when you'll get AFib, if you'll get AFib. But a few studies have suggested that the risk of AFib increases significantly after about 1, 500 to 2, 000 lifetime exercise hours. Where if it's above that level, you're at a higher risk for AFib. If you're below that, you're at less of a risk for AFib, but when it comes to detraining, there really are no large, well done studies of detraining in athletes. Anecdotally, historically, that has been recommended, and for some people it actually does work fine. So those athletes tend to have to make a decision whether they're okay with detraining or, or toning down their exercise, or whether, you know, they don't care if they're an AFib or the symptoms are not bothersome enough for them to, to detrain. But I recently learned that there's a trial, I think in, in Norway called the Nexaf Detraining Trial, which is looking at this question specifically and as far as I know, this will be at least the biggest or. Or most well done hopefully. randomized trial, randomizing athletes with AFib either to detraining or to to usual exercise. And I think that will be tremendously informative going forward.

Kanny: 21:57

Oh, that's good to know that we'll be getting more clear, clear guidance as we go forward. I want to spend the last 15 minutes or so talking about management before we finish up getting back to our original case. I know when it comes to areas of debate and discussion in AFib management, you could easily turn one podcast into a podcast series pretty quickly because there's so much we could discuss. So I kind of wanted to focus on, the areas that are potentially different from, bread and butter AF management we see in our overall patient population. And focus a little bit more about, some of the unique strategies that apply to athletes.

Ali: 22:39

So, Aura, could you talk, walk us through a little bit in this specific patient population how you would, in general, Approach the decision first of taking a rate control strategy versus a rhythm control strategy.

Auroa: 22:53

Certainly the rate control strategy is often not going to be a very good choice, especially if we're talking about an active elite athletes. This is population that medication such as beta blockers or non dihydropyridine, calcium channel blockers would likely lead to potentially reduced performance, fatigue. And some of them are frankly banned. Like if you look at the World Anti Doping Agency, I think you will have to have exception if you want to use a beta blocker in somebody who's competing at an Olympic level, for example. Generally, those medications can potentially have side effects and not the desirable first line necessarily in in a young population. So often time rhythm control strategy would be preferred, especially if there's some symptoms. Symptoms can be very vague in these population. Like our athletes has some vague symptoms, but he probably did attributed to something else. So when we talk about rhythm control, generally we're referring to like antiarrhythmic drugs or ablation. And there is a lot of problems with antiarrhythmic drugs again in this population. You can potentially use class one C such as flaconide, propafenone as a pill in the pocket and people who have very seldom and sporadic episodes and potentially you can use it as a mainstay in people who have more frequent episodes. The problem with class one C, and this is again, anecdotal, we don't have like large trial looking at that in this particular population. To me. The problem with it is that as you recall with basic electrophysiology, that there's something called dose dependent, dependent effect of a class one C, which means their toxicity, because of the affinity to the sodium channel can increase with higher heart rates. So think about a competitive athletes getting his heart rate close to one 80 beats per minute, one 70 beats per minute. Potentially they can have a toxic effect of this drug. And if the, the other possibility is that they can with AFib, they can degenerate into a true flutter, which can conduct extremely fast in a healthy AV node. And then we're going back to using beta blocker in this scenario, and so that's, that's where the problem happened. And so, not to mention, you know, if we're talking even a younger population, adherence with taking the medications and other issue related to that. So for all these reasons, antiretroviral drugs probably not the best choice. Or rate control for those drugs. And again, I might be biased being an electrophysiologist, but the technology had evolved considerably with ablation. That makes it a safe, desirable options for symptomatic athletes with a very good success rate. I mean, it's the success rate, at least in in the small studies that's been published in this particular population is similar to the non athletic population when it comes to freedom from arrhythmia and follow ups. population.

Ali: 26:31

Thank you for talking us through that and some of the specific challenges of the physiology of the athlete with both the high vagal tone and the resting bradycardia that many of these because of their high level of conditioning, moving on to hear a little bit more about ablation. Could you talk a little bit more about what some of the return to play could look like after getting an AFib ablation?

Auroa: 26:59

Yeah, I think that Generally speaking it is acceptable to go back to training fairly quickly, like within less than two weeks. This is not a procedure that's would potentially cause a lot of downtime, and we can clear people fairly quickly for even intense exercise, so long that you know, his, the access point in the femoral vein, which is typically how we perform those ablations had healed. The only issue with that is, as you know, that anticoagulation is usually needed. immediately after ablation bleeding. and so, there is considerable data now that truncating that three month of anticoagulation post ablation could be reasonable in a lot of population with a that does not have like persistent atrial fibrillation and they don't have a extensive scarring or a low voltage in their atrium and you did not perform an extensive ablation, you just did pulmonary vein isolation and those population truncating that anticoagulation period to like six to eight weeks instead of 12 weeks, for example. might be reasonable, especially if they have contact sport. Um, Um, Some of the things to consider in contact sport athlete is potentially doing the ablation in the off season. So we had to do that in some of the professional athletes in San Antonio where we try to arrange for the procedure to be done when they're done with the season and they're less likely to have any contact sport.

Brad: 28:51

Another point that I want to make is. it goes back and this is specifically a challenge with people who require multiple ablations. It goes back to the old saying of, you know, the, the surgery was a success, but the patient died where, you know, you do have an ablation and you do another ablation, you do another ablation. And, you know, ultimately you get rid of the AFib, but there is this risk of, you know, what's colloquially known as a stiff left atrial syndrome, where you, you ablate so much there, you cause fibrosis. And much there, you cause fibrosis. And, um, ultimately, you know, they may not actually feel better even in sinus rhythm.

Kanny: 29:31

that leads me to a follow up question, I think what many of the topics Auro brought up, put some focus on the concept of shared decision making, which, as a fellow sports cardiologist, I think sports cardiology is one of the areas where shared decision making is even more prominent. Then a lot of other areas because there's not a huge evidence, database guiding a lot of the decisions. So, as, as a sports specialist, can you just briefly walk us through like how you approach shared decision making when it comes to either return to play or going ahead with evidence based, medication or even, even, you know, discussing the pros and cons of a procedure like ablation with an elite athlete,

Brad: 30:13

right? I mean, this is a really good question. It's an important topic because shared decision making. You know, at least over the past 5 10 years, it's become a central tenant of the entire field. And especially in a situation like this, or situations like these, where everything that we're doing, it's all based on extrapolation from other patient populations. So, you know, we're extrapolating what to do with these patients based on the general population, you know, even for something like the CHADS VASc score. You know, the chance of ask wasn't developed in cohort of elite athletes. It was developed, you know, in a, in a more general population. So when it comes to discussing shared decision making and these decisions with athletes, I'm always very transparent in, allowing them to know, what is evidence based, what is anecdotal, what is expert consensus, because, that can change some people's mind. Whereas one person may be willing to take the risk of exercising on anticoagulants, other people may not be, and it's a risk, it's a risk benefit discussion, because for some people, if they cannot participate in their sport, then they cannot make a living for themselves and for their family, um, and so it's a sensitive and so it's a sensitive topic in certain situations. At the end of the day, it's, it's always our goal to discuss what are the risks, what are the benefits, what are their options. Does the person have and you know, ultimately, in my opinion, people have you know, the ability to make decisions for themselves, but unfortunately, if they're playing in some of these professional leagues, you know, there may be medical committees or the the team, the team physician, the trainers, the owner, they may also have some saying, and there can be some, some clashing of opinions and, you know, it really involves, it really necessitates that everyone's on the same page.

Kanny: 32:20

In fact I'd actually like to spend the last few minutes coming back to our case patient because he actually illustrates a lot of the points you just made about shared decision making. Just to summarize, he had a cardioversion, but being that it was the start of his season and the fact that this was a single documented episode of AF, you know, he certainly didn't want to rush into an immediate ablation without, having more information. So Arwa, you, you, in conjunction with his cardioversion, I know you made a decision about ongoing monitoring that I thought was very interesting and unique. What was your thought process behind Uh, the decision,

Auroa: 32:59

yeah. So this particular athlete had some vague symptoms and palpitations in the past, and it wasn't very clear. He also had a very unique substrate because he was discovered to have technically is in a, in a small category of folks who have persistent AFib in this population. Most of them has paroxysmal AFib. And so we wanted to really know what are we dealing with? So part of the whole imaging identifying substrate, identifying like Brad mentioned triggers, which is very important, which we do in any of those ablations before we do the pulmonary vein isolation. And I wanted to emphasize that, which is basically looking for accessory pathways, concealed accessory pathways AVNRT like a simple SVT that triggers you know, AFib in this young population. Part of all that we discussed implantable cardiac monitor. So loop recorder, basically implantation for various reasons. One of it is to have a true longitudinal surveillance of any recurrences in the future. In addition you know, like traditional Wearable monitors with patch and whatnot, especially if you're in a peak season is unlikely to give you any good yield because of the adherence of the because of the sweatness of the body when you're exercising. So for all these reasons, we suggested an implantable loop recorder to see again, like, what is the What is the frequency of this? Is there any correlation with exercise? All that. And yeah, the, the, the athlete underwent ILR implants. It would not affect his exercise abilities, and we're using that to really longitudinally treated now for recommendation of management. We would not have recommended ablation from the get go. It was more of to see what we're dealing with. And he does have true paroxysmal AFib now. And because of the vague symptoms that he has, minimal symptoms that he has, and an ablation is offered that potentially may be done in the off season. And that's after a very long discussion with him and in the presence and without the presence of his medical doctor from or managers from the team, because I think and I want to emphasize this ultimately the athlete has to make that decision and it should not be anybody else. Sometimes when you're dealing with these athletes, there's, there might be some. different dynamics in the room. Because there is you know, people might have different opinion on what's best for the team. And the athletes might have a opinion about should have an opinion about what's best for him. And so ultimately, it has to be his decision. So some of those discussions should be done privately with the athletes himself without the presence of managers and other people from the team. And if he choose to reveal this information to them and involve them in the decision making, that would be his choice.

Kanny: 36:41

Yeah, so I think that's very fascinating because I really could not find any case reports in the literature of uh, athletes at a professional level competing with an I. L. R. You know, to monitor their burden of arrhythmia.

Auroa: 36:56

I would like to add, I do think that you know, the arrhythmia in this population might be under reported again. This was an incidental finding. One of my colleagues at University of Illinois, my junior fellow they did a study where they implanted. 20 loop recorder in ultra triathletes folks who have a massive VO two max actually objectively studied and they discover about 5% which is really one patient who had asymptomatic atrial fibrillation. So I do think There is some value. I mean, what does that mean? How does that affect? That longitudinally? We don't know. But more and more, even in clinical trials and electrophysiology, loop recorders are becoming like the way to monitor. Especially if you really need to know about every episode.

Kanny: 37:56

Yeah. Yeah. That's that's fascinating to me. Well, just as an aside, you know, now that we've been monitoring his device for the, for the last several months, his overall burden of a fib has fluctuated between about two or 3 percent some months up to about 5%. The longest episode is about three to four hours. And but what I really think is interesting is that almost all the episodes have occurred at rest. and with low heart rates. Does that give you any insight into like the mechanism in him specifically?

Auroa: 38:27

Yeah. Excellent point. I mean, that's again, like understanding like what triggers a fib in athletes. Yes, I do think it's probably related to high bagel tone as opposed to the shares sympathetic activity. I mean, even at rest the athletes have objectively higher incidence of of PACs and PVCs and in a susceptible heart they, they potentially can go into a fit. I mean, fascinating how it is a steady and it's not following the natural progression of a fib where it's increasing in frequency and increasing which you would see and expect in an aging population. So it's not very clear. One thing I want to comment also always part of the mechanisms ask about, yeah. No. Did you get it when you have a big gulp of water immediately after exercise? Those questions like a detailed history is extremely important in this population.

Kanny: 39:31

Yeah. Yeah. So obviously the patient is waiting, awaiting ablation based on his, you know, time course and, and personal issues. Uh, so So hopefully we'll have more information. going forward. I think we're up against our time. It's been a great discussion and there's so many other aspects of this. I think we could talk about, but I think we have been able to hit on a lot of the key points related to AF in this patient population. So I want to thank my co host Ali. You did a great job on your inaugural podcast. Really appreciate your insight. And of course, I want to thank both of our guests as well. And And, uh, I think there's so many interesting things in sports cardiology we can address. So hopefully, Brad, we can get you back on podcast in the future to get more insight going forward.

Ali: 40:20

Thank you all. I really learned a lot tonight. I think our audience will too.

40:24

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,