Return-to-play protocol ‘essential’ for elite athletes at risk for sudden cardiac death
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NEW ORLEANS — Elite athletes with genetic risk for sudden cardiac death can safely return to play with a shared decision-making model that includes careful evaluation, risk stratification and tailoring of genetic heart disease therapy.
In a new retrospective study that assessed the experiences of college- and professional-level athletes with genetic heart disease that predisposes them to sudden cardiac death, 95% had no cardiac events during 7 years of follow-up.
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This study is the first to assess the risk of potentially life-threatening arrhythmias among National Collegiate Athletic Association (NCAA) Division I and professional athletes with genetic heart disease.
“One of the most-debated questions in sports medicine right now is: Should shared decision-making practices be used by experts to evaluate athletes with genetic heart disease and, potentially, allow them to return to play?” Katherine A. Martinez, an undergraduate student at Loyola University Maryland, who conducted the study as an intern in the Mayo Clinic Windland Smith Rice Sudden Death Genomic Laboratory, said during a late-breaking clinical trials session at the American College of Cardiology Scientific Session.
Recommendations ‘out of caution’
The 36th Bethesda Conference guidelines, published in 2005, stated that phenotype-positive athletes with genetic heart diseases should be disqualified from any sport apart from those designated class IA, Martinez said.
“This limited these athletes to bowling, cricket, curling, golf, riflery and yoga,” Martinez said. “At this time, these guidelines were not based on observational data, but out of an abundance of caution for disease, with a potential exercise-induced sudden death risk.”
Data published in 2012 on athletes with long QT syndrome who competed against the Bethesda guidance, along with research from a single-center study published in 2021, challenged such disqualification, Martinez said, showing at-risk athletes experienced few cardiac events after treatment optimization and shared decision-making.
For the new study, Martinez and colleagues analyzed data from 76 elite athletes treated for genetic heart disease —including hypertrophic cardiomyopathy (53%) and long QT syndrome (26%) — who were cleared for return to play at the NCAA Division I level or professional level. Mean age was 23 years, 28% were women and 64% played NCAA Division I sports. Athletes received care at Mayo Clinic, Morristown Medical Center, Massachusetts General Hospital and Atrium Health Sports Cardiology Center. The researchers assessed the athletes’ clinical diagnosis and managements, circumstances surrounding return to play and the genetic heart disease-associated cardiac event rate.
Most athletes (63%) were asymptomatic prior to diagnosis and had their genetic heart disease detected during routine preparticipation CV screening; the remaining athletes were diagnosed due to symptoms suggestive of genetic heart disease. Most athletes (72%) were initially disqualified but ultimately opted for unrestricted return to play after comprehensive clinical evaluation and implementation of shared decision-making.
The return-to-play protocol included a comprehensive evaluation with risk stratification, establishing a genotype- and phenotype-tailored treatment program and implementing a proper, athlete-specific return-to-play plan, Martinez said.
Cardiac events rare
After a comprehensive evaluation, treatment optimization and shared decision-making, three athletes (4%) chose not to return to their sport. Four of the athletes were cleared to return to play, but remained disqualified due to their team’s medical professionals.
Of the remaining athletes, three athletes (4%) had at least one breakthrough cardiac event after return to play during a mean follow-up of 7 years, including receiving an ICD shock or episodes of syncope with and without seizure.
“A comprehensive return-to-play protocol is essential to an athlete’s safe return to play and must include adherence to prescribed treatments, a personal AED, annual follow-ups and risk evaluation, and open communication with the school, organization and athletic directors and/or medical staff,” Martinez said.
Considering patient preference
During a discussion after the presentation, J. Sawalla Guseh, MD, instructor in medicine at Harvard Medical School and cardiovascular physician-scientist at Massachusetts General Hospital, said historically professional societies have been “more paternalistic,” and should instead consider patient preferences and their risk tolerance regarding to return to play after diagnosis with a genetic heart disease that predisposes to sudden cardiac death.
“We know that athletes come from all walks of life and they are intelligent,” Guseh said. “When there is scientific uncertainty, their values should be incorporated into decision-making.”
The researchers encouraged clinicians who know a college, semi-professional or professional athlete diagnosed with a cardiac condition to refer them to the Outcomes Registry for Cardiac Conditions in Athletes. More information is available at www.ORCCAStudy.org.
References:
- Johnson JN. JAMA. 2012;doi:10.1001/jama.2012.9334.
- Tobert KE, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.04.026.
Perspective
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Eugene Chung, MD
This study looked at 76 high-level athletes, either NCAA Division I or elite-level athletes. It was impressive that most of them, 72%, were initially restricted or disqualified, and then with a protocol in place at four very experienced centers, 96% opted to return to play. This is a huge turnaround. This shows the importance of having an established protocol for having these conversations, as well as going to people who see these conditions regularly. These data show that even with these inherited conditions, return to play is low risk. I look forward to seeing long-term data from the researchers and applying this model to the everyday athlete, and not just the elite athletes.
These data will help us to rewrite some of the guidance in this area. Data like these are exactly what we need to keep moving that needle.
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Martinez K, et al. Late-Breaking Clinical Trials V. Presented at: American College of Cardiology Scientific Session; March 4-6, 2023; New Orleans (hybrid meeting).
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