Q&A: Athletes with heart disease may yet compete; shared decision-making crucial
Key takeaways:
- New guidance states that some athletes with CVD may be able to safely compete.
- Shared decision-making is crucial to determining whether to allow an athlete with CVD to compete.
The American Heart Association and American College of Cardiology issued a scientific statement detailing clinical guidance on competitive sports participation for athletes with cardiovascular disease.
Published in Circulation and the Journal of the American College of Cardiology, the 11-part document provides guidance for sports classification, preparticipation screening, ethics of sports eligibility and considerations for a variety for cardiac abnormalities.
Jonathan H. Kim, MD, director of sports cardiology and associate professor of medicine in the division of cardiology at Emory University and chair of the guideline writing group, said shared decision-making between practitioners and their athletic patients should be the foundation of sports participation ethics.
The document also includes sports participation guidance for unique groups such as masters athletes, individuals competing at high altitudes, athletes who scuba as well as athletes who desire to compete while pregnant.
Healio spoke with Kim, who is also head team cardiologist for the NFL’s Atlanta Falcons, the NBA’s Atlanta Hawks, MLB’s Atlanta Braves, WNBA’s Atlanta Dream and MLS's Atlanta United about the updated guidelines and how they can be used to guide care of the athletic heart.
Healio: Can you provide some background on this scientific statement, why it is needed and for whom it is intended?
Kim: This fits in line with a more-than-40-year continuum of providing clinical guidance to practitioners who take care of competitive athletes with underlying heart conditions.
The last iteration was published in 2015, and there have been many changes over the last 10 years, and those recommendations were outdated.
There has been a paradigm shift in sports cardiology, really all of medicine, with a focus on shared decision-making and incorporating the patient in the decision-making process. In the past, this process completely excluded the athlete, and the doctors were just telling the athlete what they could or could not do.
Sports cardiology has become highly complex. There is demand for practitioners, and thus a need to have these documents up to date and acknowledging all the existing challenges to guide practitioners who maybe do not see as many athletes, but have a base to talk to the athlete and understand when it is time to get that sports cardiologist into play.
This document is for practitioners who take care of athletes, including cardiologists, not just general cardiologists or sports cardiologists, but electrophysiologists, interventional cardiologists, preventive cardiologists and pediatric cardiologists. Beyond the space of cardiology, general pediatricians and sports medicine practitioners too. Most athletes are individuals younger than 18 years, so it is critical to involve more pediatricians. It is really for any practitioner who cares for athletes.
Healio: Can you provide some details on how the writing committee came to its consensuses detailed in the scientific statement?
Kim: Similar to past documents, we split each disease grouping into a task force, which were comprised of experts in sports cardiology and those disease-specific categories. Within that task force, there was a chair and other contributors who put together these clinical considerations.
The core group of authors who were represented by the primary chairs, not just myself, but also Aaron Baggish, MD, FACC, and Benjamin D. Levine, MD, FAHA, FACC, got together with the task force chairs and reviewed the clinical considerations. With many of these considerations, we were in unanimous agreement. For more controversial considerations, there were discussions to ultimately come to a consensus about the best way to present that consideration.
Healio: What are some of the major differences between the current document and its 2015 iteration?
Kim: These clinical considerations are grounded in shared decision-making and incorporating the athlete into the decision-making process. That is the biggest difference. It was kind of addressed in the 2015 document, although the term shared decision-making was never used.
We also made many disease-specific changes. For a lot of diseases where it was initially pressed upon athletes their risk was too high, there are no longer as strict “lines in the sand” as there used to be. This is not a document about sports disqualification. This is about a discussion of risk and shared decision-making about certain conditions and individuals who may have them and want to play competitive sports.
At the same token, this is not a green-light document. By no means is this saying, “If you have disease X, you can do whatever you want.” It is about taking into account many different factors and, through a shared decision-making process, coming forth with a decision.
With this, we help guide where perhaps risks may be lower or higher.
For genetic cardiomyopathies, that is a big change. It used to be a line in the sand. You do not see that in this iteration. Instead, there’s acknowledgement where maybe in some conditions risk could be higher or others where risk is not as high as previously thought.
For myocarditis, you previously had to wait at least 3 months before going back to sport. We now know that may be too conservative.
Conditions with the aorta also used to be a line in the sand. There are some aortopathy conditions where risk is probably very high and may outweigh the benefits of sports. But maybe others where the risk is probably not so high, and there is a chance for athletes who have some degree of aortic enlargement to play sports.
For some arrhythmia syndromes, like long QT, changes were made in 2015. For other conditions such as catecholaminergic polymorphic ventricular tachycardia, another channelopathy, we have single-center data showing, under appropriate supervision, competitive sports can be considered.
We have a whole new section on the masters athletes; including sections for athletes who have coronary disease or arrhythmias, like atrial fibrillation. The last section covers miscellaneous items. It includes athletes with a history of blood clots or pulmonary emboli and athletes who are engaged in extreme sports like exercise at high altitude or scuba. While obviously not a disease process, the last section also discusses competitive sports participation for pregnant athletes.
In addition, when we talk about screening, ECG screening was only considered for very select and very small populations in the past. Data have shown that ECG screening does provide improved sensitivity to detect important cardiac conditions, which could potentially put an athlete at higher risk. We now say that it is reasonable to do ECG screening as long as you have the right individuals reading the ECGs and have a carefully thought through ECG screening program to ensure that all the downstream testing is equitable for all athletes.
Healio: What is the significance of updating the classification of sports in Section I?
Kim: It is impossible to put a single sport into perfectly outlined classifications. You can be a competitive golfer, which is considered a low-intensity sport. But we know certain pro golfers, collegiate golfers and even high school golfers put much more effort into intensive training. Depending on the level of intensity, what part of the season they are in, the mentality of the athlete, the sport type, it is impossible to put sports into categorized boxes. Rather, it’s a continuum of different intensities, strength and endurance for most sports. This also fits into a shared decision-making paradigm in which unique aspects of each sport should be considered based on the cardiac diagnosis.
Healio: Section II contains updates on preparticipation screening and emergency action planning. Could you summarize its main takeaways?
Kim: Screening should still begin with a history and physical. Even though the sensitivity is not very high in terms of detecting cardiac conditions in an asymptomatic athlete, it is a chance to bring the athlete in front of a medical practitioner for basic things, like BP, family history and maybe detecting symptoms. Everything begins with a good history and physical. The addition of a screening ECG improves sensitivity and is reasonable to include now, based on data acquired over the last decade, so long as the appropriate expertise is present to interpret the ECG and the downstream resources have been carefully considered and planned to ensure equitable outcomes for all athletes who are screened.
We wanted to emphasize that no matter what you do, how intensive a screening process exists, unfortunately, cardiac events can still occur. That is why we strongly recommend emergency action planning. If you take care of athletes, you must know what sudden cardiac arrest looks like, because it is unfortunately going to happen no matter what you do for primary prevention. You must know CPR; ensure an automated external defibrillator is nearby; and know what the plan is when an emergency arises. This means practicing that emergency action plan and having it written and re-vetted at least on an annual basis. We also wanted to emphasize that while having an emergency action plan is important, access must be universal. Particularly for those athletes who may reside in more underserved areas in the country.
Healio: Section III is new. What exactly defines ethics in sports eligibility?
Kim: This was our chance to talk about shared decision-making. That is the foundation for this whole document. To emphasize this principle, how to think about it and how to try to incorporate the process within the care of your athletes. I encourage everybody who reads this document to read that section in detail. Most providers in sports cardiology recognize this, and this is certainly not a new concept, but it’s important that everybody recognizes how important shared decision-making is.
Healio: Sections IV to XI detail guidance for specific CVDs, but section X includes considerations for masters athletes. How do you define masters athletes and what does this section add to current knowledge base for the care of these individuals?
Kim: This is based on terminology in the literature. In the U.S., we define it as athletes 35 years of age or older. The reason why this is important is the population of masters athletes, not just in the U.S. but around the world, is growing. We understand there are certain CV pathologies and risk factors that are more common as you get older and separate from when you are a young competitive athlete.
This is the population generally most encountered in the sports cardiology clinics.
Healio: Is there anything else you would like to say about this document?
Kim: This was an international collaboration. In the past, it was U.S. experts coming together and we wanted to acknowledge that sports cardiology is growing internationally too. The spirit of a collaborative cooperative effort among experts who reside on different continents, but still caring for the same population, is important to emphasize.
For more information:
Jonathan H. Kim, MD, can be reached at 5671 Peachtree Dunwoody Road, Fl 3, Ste 300, Atlanta, GA 30342.
References:
- Kim JH, et al. Circulation. 2025;doi:10.1161/CIR.0000000000001297.
- Kim JH, et al. J Am Coll Cardiol. 2025;doi:10.1016/j.jacc.2024.12.025.
- Latest research finds people with certain heart conditions may play competitive sports. https://newsroom.heart.org/news/latest-research-finds-people-with-certain-heart-conditions-may-play-competitive-sports. Published Feb. 20, 2025. Accessed Feb. 20, 2025.
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