HRS: Return-to-play decision for athletes with arrhythmias should be individualized
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Key takeaways:
- According to an HRS expert statement, shared decision-making should be employed for athletes with arrhythmias who wish to return to play.
- An individualized plan should be made following risk assessment.
For athletes with arrhythmias, the return-to-play decision should be individualized based on appropriate risk assessment and treatment and the shared decision-making process should be used, according to a new expert statement.
The Heart Rhythm Society Expert Consensus Statement on Arrhythmias in the Athlete: Evaluation, Treatment and Return to Play was presented at Heart Rhythm 2024 and simultaneously published in HeartRhythm. It takes into account recent studies that have shown that for many cardiac conditions, continued sports participation may not raise risk in athletes whose heart conditions are appropriately managed and treated.
Returning to play
“What makes this document unique is that we have moved away from a focus on if an athlete with a cardiovascular condition can return to play to a focus on how can we optimize the management of that athlete-patient to get them back onto the field, on their bike, in the pool, if that’s their goal,” Rachel Lampert, MD, FACC, FHRS, Robert W. Berliner Professor of Medicine (Cardiology) at Yale School of Medicine and chair of the writing committee, told Healio. “The overarching goal in caring for athletes should be getting the athlete back into their sport through the appropriate risk assessment and athlete-focused management of their condition whenever possible. We want to focus on optimizing their management to get them back to living the life they want to live.”
According to the statement, evaluation of athletes with arrhythmias should be performed by clinicians who understand the structural and electrical adaptations of the heart to the demands of sport. The process should include stress tests based on maximal effort and/or symptom reproduction, and on sport type and situation where symptoms occur. In addition, a stress test should be performed prior to the athlete returning to play to confirm that interventions have gotten arrhythmias under control.
The authors also wrote that the clinical management strategy should consider the limitations on the athletic performance that are caused by the arrhythmia or any medications for it, and that management decisions should include athlete- and sport-specific considerations.
Making plans
“We see the role of the physician as working with the athlete to help them understand their condition, risk assessment and existing data. Next step is to help them determine their goals and preferences, as with all shared decision-making, and then talk about the options for management of their arrhythmias to help them achieve those goals,” Lampert told Healio. “The document includes specific recommendations about what evaluation is needed in different situations, when is it OK to return to play during evaluation and when should we be waiting until we have the diagnosis and management plan.”
The document also states that venue-based and individualized action plans, including plans for early defibrillation, are crucial to the survival of athletes who experience sudden cardiac arrest. In addition, any athlete who collapses and is nonresponsive should be presumed to have sudden cardiac arrest and treated accordingly.
The authors recommend “periodic preparticipation evaluations including screening for [sudden cardiac death] risk” for athletes, and that athletes who have a condition predisposing to sudden cardiac death risk who are returning to play should have an individualized emergency action plan.
“We emphasized the fundamental principle of having a well-planned and well-rehearsed emergency action plan (EAP) in place. An EAP is essential for enhancing the safety of sport for the athlete as well as anyone else at the venue,” Eugene H. Chung, MD, MPH, MSc, FACC, FHRS, FAHA, director of sports electrophysiology at Massachusetts General Hospital and Harvard Medical School and the vice chair of the writing committee, told Healio. “We highlighted the evolving options for implantable cardioverter defibrillators (ICDs) for those athletes who need them. New form factors may limit potential damage to an ICD system from repetitive arm movements.”
In addition, Chung said, “we strengthened the recommendations for electrophysiology study and catheter ablation for athletes with atrial fibrillation and Wolff Parkinson White ECG pattern in comparison to previously published guidelines.”
Knowledge gaps that remain, Lampert told Healio, include “the ideal workup of the athlete who passes out during exercise; understanding the impact of race, ethnicity and gender on athletes with arrhythmic conditions; and understanding best options for anticoagulation for athletes.”
Reference:
For more information:
Eugene H. Chung, MD, MPH, MSc, FACC, FHRS, FAHA, can be reached at echung13@mgh.harvard.edu.
Rachel Lampert, MD, FACC, FHRS, can be reached at rachel.lampert@yale.edu.
Collapse
Lampert R, et al. The 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment and return to play. Presented at: Heart Rhythm 2024; May 16-19, 2024; Boston.
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