Should athletes with genetic heart disease return to play after sudden cardiac arrest?
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Key takeaways:
- Recent evidence suggests it may be reasonable for elite athletes with some types of genetic heart disease to return to play after sudden cardiac arrest.
- A shared decision-making process should be followed.
Recently, there have been a number of cases in which high-profile athletes have had sudden cardiac arrest due to a variety of causes.
Christian Eriksen, Damar Hamlin and Bronny James all represent athletes of different ages and athletic vocations who have had a sudden cardiac arrest (SCA). Athletes with genetic heart disease (GHD) represent a specific subgroup who have traditionally been advised to abstain from participation in vigorous sports. However, to date there has not been comprehensive or consistent information as to whether it is safe for athletes with GHD to return after having an SCA.
SCA risk
SCA has been referred to as the leading medical cause of death during exercise among young athletes. The majority of SCA episodes occur in structurally normal hearts. Among those with identifiable abnormalities, common pathologies include hypertrophic cardiomyopathy (HCM), anomalous coronary arteries, arrhythmogenic cardiomyopathy and channelopathies such as long QT syndrome. Physiologic stress that occurs during exercise such as dehydration, electrolyte imbalance and adrenergic surges have been shown to increase the risk for arrhythmic events. Less common causes of SCA also include superimposed electrical insults, such as the “R on T” phenomenon due to an ill-timed blow to the chest, known as commotio cordis, that characterized the widely publicized SCA of Hamlin, a safety for the Buffalo Bills.
Historically, athletes with GHD have traditionally been advised to abstain from participation in vigorous sports due to concern for cardiac events, even among those who have not previously had SCA. However, subsequent studies have shown no increased rates of SCA in those participating in moderate (RESET-HCM) and vigorous (LIVE-HCM) activity. Moreover, in a cohort of individuals with long QT syndrome, a recent study demonstrated an event rate of SCA of 1.16 per 100 athletes.
Return to play
In 2015, the American Heart Association/American College of Cardiology produced a statement highlighting that decisions regarding return to play (RTP) should be made on a case-by-case basis using a shared decision-making model that identifies the initial causes for cardiac arrest and allows the patient to weigh the risks and benefits. Crucial to this approach is identifying the risk threshold of the individual patient. Furthermore, concerns regarding professional liability as well as the nature of competitive athletics have complicated repercussions, and a new set of comprehensive guidelines for when RTP is warranted.
As noted by a recent publication in the Journal of the American College of Cardiology by Katherine A. Martinez, BS, one of the authors of this column, and colleagues, there is evidence that, for elite athletes with GHD, RTP should be composed of shared decision-making along with comprehensive diagnostic evaluation. In particular, the study demonstrated that after SCA, no subsequent fatalities or cardiac arrests were noted after RTP.
Although limited by a low number of participants, this study is the first of its kind and provides important insight into the outcomes of individuals identified with GHD who receive appropriate medical care and RTP. Just one of 76 elite athletes with GHD experienced sport-related breakthrough cardiac events, whereas two others experienced cardiac events unrelated to their initial presentation. For example, one male basketball player with HCM had cardiac arrest before receiving an implantable converter defibrillator for secondary prevention as well as a beta-blocker, ultimately returning to play thereafter. He was noted to have had an appropriate ICD shock after moving furniture, unrelated to his sport.
In addition, a male hockey player presented with long QT syndrome secondary to a syncopal episode and was also treated with a beta-blocker before returning to play. He did well initially, but subsequently experienced two episodes of syncope approximately 3 years later. One of these events occurred while he was coming off the bench and the other during a meal, both of which were not directly related to physical activity. He subsequently returned to play without any additional events. Lastly, a male hockey player with HCM also experienced syncope and, after evaluation, returned to play untreated. Subsequently, he experienced another syncopal episode while working out. He was started on a beta-blocker and returned to play with no subsequent episodes.
Historically, the standard of care was that athletes with GHD who had SCA were advised to abstain from competitive sports completely. Expert consensus documents such as the Bethesda Conference proceedings provided a binary, yes/no approach to RTP after a diagnosis of cardiac disease. Recommendations for the most part were made based on “prudence” without evidence, with a tolerance for risk of zero — ie, only those with risk no more than the general population should be allowed to participate in sports. This approach to eligibility fostered paternalistic decision-making in which physicians and institutions made decisions without input from the athletes and their families.
An unfortunate additional consequence was athlete distrust and reluctance to seek evaluation for symptoms or to report known family history of CVD out of fear of being disqualified. The findings by Martinez and colleagues suggest that shared decision-making may be appropriate for athletes with GHD who wish to return to sport after being counseled appropriately. Importantly, shared decision-making should be guided by conversations related to mitigating secondary cardiac events, such as having comprehensive emergency action plans in place, acquiring personal automated external defibrillators or receiving an ICD for secondary prevention.
Patient-centered approaches needed
In summary, Martinez and colleagues demonstrated that it may be reasonable for elite athletes with some types of GHD to RTP with appropriate medical treatment and monitoring. While the conventional approach has been cautious regarding RTP — primarily due to the perceived high sports-related risk for SCA in those with underlying GHD — recent data suggest rates of subsequent cardiac events may be lower than previously thought, as evidenced by Rachel Lampert, MD, FACC, the Robert W. Berliner Professor of Medicine (Cardiology) at Yale School of Medicine, and colleagues in LIVE-HCM. Notably, most (69 of 76) athletes in the RTP study have since returned to play at the elite level with minimal subsequent cardiac events.
This evidence suggests that more patient-centered approaches could be favorable, and that shared decision-making may be an effective method toward determining optimal timeframe to RTP for patients with GHD through appropriate risk stratification and a discussion of existing alternative solutions.
References:
- Corneil H, et al. Curr Probl Cardiol. 2023;doi:10.1016/j.cpcardiol.2023.101815.
- Dijkstra HP, et al. Br J Sports Med. 2017;doi:10.1136/bjsports-2016-096209.
- Lampert R, et al. JAMA Cardiol. 2023;doi:10.1001/jamacardio.2023.1042.
- Maron BJ, et al. J Am Coll Cardiol. 2005;doi:10.1016/j.jacc.2005.02.006.
- Martinez KA, et al. J Am Coll Cardiol. 2023;doi:10.1016/j.jacc.2023.05.059.
- Oksuz F, et al. Indian Heart J. 2015;doi:10.1016/j.ihj.2015.02.030.
- Schaffer R. https://www.healio.com/news/cardiology/20230306/returntoplay-protocol-essential-for-elite-athletes-at-risk-for-sudden-cardiac-death. Published March 6, 2023. Accessed Sept. 5, 2023.
- Tobert KE, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.04.026.
- Wasfy MM, et al. Methodist Debakey Cardiovasc J. 2016;doi:10.14797/mdcj-12-2-76.
- Weissler-Snir A, et al. Circulation. 2019;doi:10.1161/CIRCULATIONAHA.119.040271.
For more information:
Deen L. Garba, MD, is a junior assistant resident in the Osler Medical Residency at Johns Hopkins Hospital. X (Twitter): @deengarba.
Katherine A. Martinez, BS, recently received a Bachelor of Science degree from Loyola University Maryland and is working for Michael Ackerman, MD, PhD, in the Graduate Research Education Program at Mayo Clinic in Rochester, Minnesota while she applies to MD/PhD programs. X (Twitter): @327katemartinez.
Alan P. Jacobsen, MB, BCh, BAO, is a cardiology fellow at Johns Hopkins Hospital. X (Twitter): @alanpjacobsen.
Roger S. Blumenthal, MD, is director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and professor of medicine at Johns Hopkins University School of Medicine. He is also the editor of the Prevention section of the Healio | Cardiology Today Editorial Board. X (Twitter): @rblument1.
Lili A. Barouch, MD, is director of the Sports Cardiology Program and associate professor of medicine at Johns Hopkins University School of Medicine, and a member of the Advanced Heart Failure and Cardiac Transplantation group at Johns Hopkins Hospital. X (Twitter): @lilibarouch.
The authors can be reached at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Halsted 560, Baltimore, MD 21827.
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