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Physical activity is consistently associated with reduced risk of vascular and non-vascular outcomes as well as mortality. Vigorous or high-intensity physical activity (HIPA) (defined as energy expenditure of >6.0 metabolic equivalents of task (METs)) is associated with substantial improvements in cardiovascular risk factors such as cardiorespiratory fitness (CRF) and larger reductions in the risk of vascular outcomes. Crosscountry skiing is a seasonal HIPA which is undertaken as a leisure-time physical activity or long-term endurance sport; it is recognized as one of the most demanding aerobic endurance activities requiring good CRF. Emerging data suggests that cross-country skiing, undertaken as either a leisure-time or endurance training and competitive activity, is associated with reduced risk of vascular diseases, as well as mortality. There are suggestions that HIPA might be associated with potential toxic effects such as abnormalities in biochemical markers and cardiac dysfunction and arrhythmias, especially in endurance running and cycling. However, it has been reported that this evidence is not consistent or strong enough to recommend avoiding heavy endurance exercise or sports. Some reports suggest that cross-country skiing may be associated with an increased risk of acute cardiac events as well as common cardiac arrhythmias such as atrial fibrillation. Similarly these findings have been inconsistent; whereas some studies have shown an increased risk of atrial fibrillation with cross-country skiing, others have shown decreased or no difference in risk. In this context, our primary objective was to evaluate the associations of total volume and duration of leisure-time cross-country skiing with the risk of incident atrial fibrillation in a large general population-based sample of middle-aged Finnish men aged 42–61 years at baseline. Secondary objectives included (i) assessing the associations of leisure-time cross-country skiing habits with the risk of incident stroke and (ii) assessing the joint associations of leisure-time cross-country skiing habits and CRF with the risk of incident atrial fibrillation and stroke. Data employed for this analysis came from the Kuopio Ischaemic Heart Disease Risk Factor (KIHD) study, a prospective population-based cohort study designed to investigate potential risk factors for atherosclerotic cardiovascular disease and other related chronic disease outcomes. Methods for participant recruitment, baseline examinations and measurements have been described previously. Baseline measurements were performed between 20 March 1984 and 5 December 1989. Leisure-time cross-country skiing activity habits were assessed using a 12-month physical activity questionnaire modified from the Minnesota Leisure-Time Physical Activity Questionnaire. All incident cases of atrial fibrillation and stroke from study entry through to 2017 were included and no losses to follow-up were recorded. The diagnostic classification of atrial fibrillation cases was conducted according to ICD-10 codes (I48.0–I48.9). A stroke event was classified according to ICD-10 codes I60–I68 and G45–G46]. The protocol was approved by the Research Ethics Committee of the University of Eastern Finland in line with the Helsinki Declaration and every participant provided written informed consent. Hazard ratios with

Leisure-time cross-country skiing and risk of atrial fibrillation and stroke: A prospective cohort study