Athletes with arrhythmias returning to sport: focus on shared decision making

By Rebecca Jenkins

A newly published international consensus statement on evaluating and managing athletes with arrhythmic cardiac conditions highlights the importance of helping people with cardiac conditions safely return to sport.

The Heart Rhythm Society-led international expert consensus statement, which was developed in collaboration with several international groups, including the American College of Cardiology, was intended to guide clinicians and healthcare professionals in diagnosing, treating and managing arrhythmic conditions in the athlete, the authors said.

The document defined athletes as individuals who were exposed to regular and high cardiovascular stress demands due to habitual vigorous exercise training for the purposes of obtaining a high level of fitness for competition, occupation or recreation.

‘For many arrhythmogenic disease entities, current data in athletes, while often not large enough to be definitive, have not confirmed increased arrhythmic risk of continuing sports participation for athletes who are appropriately risk-assessed and treated, and thus the approach to return to play is one of individualized shared decision-making,’ the expert authors wrote in Heart Rhythm.

‘The overarching goal in caring for athletes should be facilitating the athlete’s return to sport if this is the desired outcome, through appropriate risk assessment and athlete-focused management of their arrhythmic condition. Restriction from sport is not benign.’

The advice applied to both adult and paediatric athletes, the authors added, noting that competitive youth sports were beginning at younger ages and genetic heart conditions, especially those with high penetrance, could affect young children.

Among the main messages, was the need for disease-specific and guideline-based risk assessment and treatment of arrhythmogenic conditions prior to return to play.

For patients with underlying complex arrhythmias, the document emphasised the need for appropriate strategies for sudden death prevention and arrhythmia suppression before returning to sporting activities, including confirmation of suppression of arrhythmia during exercise.

Any treatment decisions, including those regarding antiarrhythmic medications, ablation and devices, should take athletic performance and training into consideration, the experts recommended.

In particular, endurance exercise might contribute to arrhythmogenic conditions such as atrial fibrillation and genotype-negative arrhythmogenic right ventricular cardiomyopathy, the expert committee cautioned.

‘Risks and benefits of continued participation in endurance sports should be carefully weighed in athletes with these conditions,’ they concluded.

Statement coauthor Associate Professor Belinda Gray, Cardiologist and Director of Sports Cardiology Program at the Royal Prince Alfred Hospital in Sydney, said the advice emphasised the need for shared decision-making between all stakeholders, including athletes, clinicians, sporting bodies and families.

In addition, if GPs had athlete patients with suspected or diagnosed cardiac arrhythmias, Professor Gray advised liaising with a cardiologist and onward referral where appropriate, to ensure that dangerous pathologies were not missed, but also that athletes were not inappropriately excluded from participating in sport.

‘The focus in this document is on athletes and their stakeholders being involved in the decision making, with clinicians taking a less paternalistic approach,’ she told Medicine Today.

‘But this process is not quick; it takes time, and it requires an expert multidisciplinary team to be involved.’

Heart Rhythm 2024; doi: https://doi.org/10.1016/j.hrthm.2024.05.018.