Key Points
-Patients with diagnosed sudden cardiac death (SCD)-predisposing genetic heart diseases (GHDs) have traditionally been restricted from participating in competitive sporting activities.
-This retrospective study was the first to assess the risk of potentially life-threatening arrhythmias among NCAA D1 and professional athletes with a mean age of 22±5 years at the time of return to play.
– Over an average follow-up period of seven years, only three (3) athletes (4%) experienced a non-lethal cardiac episode related to their genetic heart disease, with fainting being the most common event. One of these athletes received an appropriate ICD shock. No athletes died during the study follow-up period.
Individuals diagnosed with sudden cardiac death (SCD)-predisposing genetic heart diseases (GHDs) have traditionally been restricted from participating in competitive sporting activities. There has been a paucity of data available to help clinicians make informed shared-decisions with patients and families. However, the concerns for adverse outcomes after return to play (RTP) include a range of scenarios which include, but are not limited to: cardiogenic fainting or seizures, implantable cardio-defibrillator (ICD) shocks, sudden cardiac arrest or sudden cardiac death. One of the largest, most contemporary studies to address this uncertainty, was a 20-year retrospective Mayo Clinic study on shared decision making (SDM)-mediated return-to-play (RTP). Although this study provided promising evidence of extremely low, non-lethal event rates, it was unfortunately, representative of a very young (<22 year of age) athletic cohort in non-elite level (Division I University or Professional) sporting activities.
In a late-breaking presentation at the American College of Cardiology’s Annual Scientific Session Together With the World Congress of Cardiology today, Katherine A. Martinez (an undergraduate student at Loyola University, Baltimore, MD) and her team presented their study: “Return-to-play For Elite Level Athletes With Sudden Cardiac Death Predisposing Genetic Heart Diseases”, which is the first to assess s the risk of potentially life-threatening arrhythmias among National Collegiate Athletic Association (NCAA) Division I and professional athletes with heart conditions that can increase the risk of sudden cardiac death.
This was a multi-center, retrospective analysis of 76 elite athletes playing at the Division I or professional level treated for GHD at Mayo Clinic, Morristown Medical Center, Massachusetts General Hospital, and Atrium Health Sports Cardiology Center. About half of the elite athletes with GHD who were cleared for RTP (40 patients, 53%) had hypertrophic cardiomyopathy (HCM), and one-quarter (20 patients, 26%) had Long QT Syndrome (LQTS). Slightly more than half of the athletes (40/76, 52%) had no symptoms prior to their diagnosis and were flagged after an abnormal cardiac evaluation, usually during pre-season screening. Approximately a quarter of athletes were diagnosed after experiencing symptoms suggestive of GHD. The remainder were diagnosed due to family history or an unrelated event. About 28% were female, with a mean age at return to play of 22±5 years. The breakdown of elite level participation was 49 (64%) NCAA D1 level and 27 (36%) at the professional level. Approximately one-third of athletes had an ICD.
The athletes included in the analysis played a range of sports, including basketball, hockey, track and field, triathlon and soccer, representing a variety of racial and ethnic backgrounds. Most athletes three-quarters (55/76, 72%) had been initially disqualified from sports based on their diagnosis but ultimately opted for unrestricted return to play after comprehensive clinical evaluation and implementation of SDM.
Over an average follow-up period of seven years, only three athletes (4%) experienced a non-lethal cardiac episode related to their genetic heart disease, with fainting being the most common event. One of these three patients received an appropriate ICD shock. No athletes died during the study follow-up period.
The results of this study by Katherine A. Martinez and team, provides hope for many patients with GHDs who wish to participate in sporting activities, particularly at the elite level. This study particularly highlights the importance of shared decision-making approaches to clinician-patient interactions as well as the need for multidisciplinary specialist involvement (genetic cardiologists and sports cardiologists among others) in the care of this patient population. This brings focus to the growing importance of an individualized approach to clinical recommendations. The devastating instances of high-profile tragedies naturally influences organizational, clinician and public perceptions of the health risks posed by GHDs in the sporting arena. However, this contemporary analysis stresses the importance of using scientific evidence in informed decision making. Prospective, multi-center data will be prudent to help bolster policy and guideline statements. The authors acknowledged that essential criteria for a comprehensive RTP protocol, must include: patient commitment to adherence to prescribed treatments and follow-up, access to an AED and open communication with relevant stakeholders overseeing elite sporting activities.
In closing, regarding the clinical implications of the study, Katherine Martinez stated: “our study provides scientific evidence, that for athletes competing at an elite level with an ICD, the outcomes are good.”