Return to Play in Athletes with Heart Disease?

Sudden cardiac death of athletes, though rare, is a shocking event for the family and often attract a lot of media attention. In the earlier era, once an athelete was detected to have heart disease either due to symptoms, pre-participation screening or family screening, they were just excluded from return to play due to the perceived risk. But this simplistic approach is changing gradually as we have data from athletes who have continued to play even after detection of some forms of heart disease. An interesting article published in JACC discusses this aspect in depth and is worth reading for everyone likely to be involved in the decision making process. Authors highlight the physical and psychological benefits of continuing to play and psychological trauma of prohibiting return to play. They do not underestimate the potential risks and analyzes the data from studies [1].

They have cited data from a few studies evaluating the risks involved [2-4]. Latest of these is on vigorous exercise in patients with hypertrophic cardiomyopathy, which was published in 2023. It was an investigator intiated, multicenter prospective study [4]. Self reported levels of physical activity was classified as sedentary, moderate or vigorous intensity exercise. This observational registry involved 42 high volume HCM centers globally and subjects aged 8 to 60 years. There were persons who had HCM as well as those who had the genotype, but was phenotype negative. Of the 1660 participants, 15% were sedentary, while 43% participated in moderate exercise. Participation in vigorous intensity exericise was noted in 42% of the individuals, of which 259 had participated competitively. Study had excluded those with conditions precluding exercise.

The primary prespecified composite endpoint of the study included death, resuscitated sudden cardiac arrest, arrhythmic syncope and appropriate shock from an implantable cardioverter defibrillator. A total of 77 individuals reached the composite endpoint of the study. 44 were in the nonvigorous group of exercise while 33 were in the vigorous group. Hazard ratio comparing the groups was 1.01 which was not statistically significant [4].

Another was a prospective international registry evaluating the safety of sports in athletes with implantable cardioverter defibrillator, published in 2013 [3]. The study had atheletes with ICD aged 10 to 60 years, of which 328 were participating in organized sports while 44 were participating in high risk sports. Median age was 33 years with 89 subjects younger than 20 years. 42% had history of ventricular arrhythmia before ICD implantation. The most common sports were running, basketball and soccer. There were no death, resuscitated cardiac arrest or arrhythmia- or shock-related injury during sports over a median follow up period of 31 months. 49 shocks occurred in 37 of the participants during competition or practice. 39 shocks in 29 participants occured during other physical activity, while 33 shocks in 24 participants occurred at rest. ICD terminated all these episodes. 97% were free of lead malfunction at 5 years from implantation and 90% at 10 years.

So the trend now-a-days is for a shared decision making, as in all other fields of medicine. It is a process involving the athlete, team physician, athlete’s family, treating physician, disease specific consultant, athletic trainers, institutional stakeholders, and sports cardiologist. Decisions should be based on sudden cardiac death risk assessment and guidelines or statements provided by professional societies [1].

References

1. Martinez MW, Ackerman MJ, Annas GJ, Baggish AL, Day SM, Harmon KG, Kim JH, Levine BD, Putukian M, Lampert R. Sports Participation by Athletes With Cardiovascular Disease. J Am Coll Cardiol. 2024 Feb 27;83(8):865-868. doi: 10.1016/j.jacc.2023.12.021. PMID: 38383101.
2. Johnson JN, Ackerman MJ. Competitive sports participation in athletes with congenital long QT syndrome. JAMA. 2012 Aug 22;308(8):764-5. doi: 10.1001/jama.2012.9334. PMID: 22820673.
3. Lampert R, Olshansky B, Heidbuchel H, Lawless C, Saarel E, Ackerman M, Calkins H, Estes NA, Link MS, Maron BJ, Marcus F, Scheinman M, Wilkoff BL, Zipes DP, Berul CI, Cheng A, Law I, Loomis M, Barth C, Brandt C, Dziura J, Li F, Cannom D. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation. 2013 May 21;127(20):2021-30. doi: 10.1161/CIRCULATIONAHA.112.000447. PMID: 23690453.
4. Lampert R, Ackerman MJ, Marino BS, Burg M, Ainsworth B, Salberg L, Tome Esteban MT, Ho CY, Abraham R, Balaji S, Barth C, Berul CI, Bos M, Cannom D, Choudhury L, Concannon M, Cooper R, Czosek RJ, Dubin AM, Dziura J, Eidem B, Emery MS, Estes NAM, Etheridge SP, Geske JB, Gray B, Hall K, Harmon KG, James CA, Lal AK, Law IH, Li F, Link MS, McKenna WJ, Molossi S, Olshansky B, Ommen SR, Saarel EV, Saberi S, Simone L, Tomaselli G, Ware JS, Zipes DP, Day SM; LIVE Consortium. Vigorous Exercise in Patients With Hypertrophic Cardiomyopathy. JAMA Cardiol. 2023 Jun 1;8(6):595-605. doi: 10.1001/jamacardio.2023.1042. PMID: 37195701; PMCID: PMC10193262.