Cautious Return-to-Play Appears Safe for Athletes With Heart Conditions

For elite-level athletes diagnosed with a genetic heart disease, the first available outcomes data on a return-to-play (RTP) protocol favored the approach, comprising shared decision-making with comprehensive diagnostic evaluation, risk stratification, and treatment.

During cumulative follow-up of 200 athlete-years, there were no fatalities or cardiac arrests after the athletes returned to their sport upon approval by one of four U.S. sports cardiology centers using the protocol, reported Michael Ackerman, MD, PhD, of the Mayo Clinic in Rochester, Minnesota, and colleagues, in the Journal of the American College of Cardiology.

Just one of 76 elite athletes with a genetic heart disease experienced a sport-related breakthrough cardiac event, and two others experienced a unrelated cardiac event:

• A male basketball player with hypertrophic cardiomyopathy (HCM) had a nonexertional cardiac arrest and was initially disqualified from play. He subsequently received a secondary prevention implantable cardioverter-defibrillator (ICD) and was treated with a beta-blocker before returning to basketball. His breakthrough cardiac event was an appropriate ICD shock while moving furniture.
• A male hockey player diagnosed with long QT syndrome (LQTS) after a syncopal episode was treated with a beta-blocker and returned to play the same year. Approximately 3 years later, he experienced two episodes of syncope with seizure-like activity: one during sport while he was coming off the bench and the other during a meal. He had his medications adjusted and returned to play without subsequent events.
• A male hockey player with HCM experienced a presumed nonarrhythmogenic syncopal episode and returned to play untreated, followed by an exertional syncopal episode while working out. He then started a beta-blocker and subsequently returned to play with no further episodes.

"These data suggest that sport after a GHD [genetic heart disease] diagnosis is both feasible and associated with low adverse event rates, even in elite-level athletes," the investigators said. An overview of their report had been presented this spring at the American College of Cardiology conference.

Diagnosis historically has led to restriction from competitive sports, but rules have been loosening for people with a genetic heart disease associated with sudden cardiac death (SCD). Despite concerns about increased risk of exercise-induced ventricular tachycardia and ventricular fibrillation, their actual cardiac event rates appear lower than previously feared after treatment.

"As a result, sports and genetic cardiology experts have gravitated toward a more patient-centered approach, utilizing the core tenets of shared decision-making (SDM), to address RTP considerations among athletes diagnosed with GHD," Ackerman and coauthors noted.

Their outcomes data, especially the 1.3% breakthrough cardiac event rate, provided a basis for confidence in this approach to RTP.

"Although additional prospective outcomes data are warranted, these data should be applauded as a necessary first contribution to the literature, which advances the landscape of this controversial issue," wrote Jonathan Kim, MD, MSc, of Emory University School of Medicine in Atlanta, in an accompanying editorial.

Nevertheless, he cautioned: "Just as this event rate does not support universal sports disqualification for athletes with GHD, it also does not espouse straight forward 'rubber-stamp' approvals for athletes with GHD who desire RTP and highlights the central role of SDM throughout RTP decisions."

The retrospective multicenter study included 50 National Collegiate Athletic Association Division I student athletes and 26 professional athletes diagnosed with a genetic heart disease. Mean age at RTP was 19.9 years, and 28% of the cohort were women. By race, 50% were white and 37% were Black persons.

The most commonly represented conditions were hypertrophic cardiomyopathy (53%) and long QT syndrome (26%); the rest of the cases were a mix of idiopathic ventricular fibrillation, arrhythmogenic cardiomyopathy, dilated cardiomyopathy, and other cardiomyopathies in smaller numbers.

Most athletes were asymptomatic before diagnosis and had their genetic disease detected during routine pre-participation cardiovascular screening (63%). They were treated with a mix of pharmacological treatments (45%), ICDs (32%, most for primary prevention), and left cardiac sympathetic denervation (8%).

All study participants were ultimately granted RTP approval at Mayo Clinic, Morristown Medical Center, Massachusetts General Hospital, or Atrium Health from July 2000 to July 2022. The majority had been initially disqualified from their sport but opted for RTP after a comprehensive clinical evaluation (72%). Just 4% chose to stop playing postdiagnosis.

Notably, the protocol required that elite RTP athletes confirm ready accessibility of an automatic external defibrillator (AED) during all training and competition, and some bought their own personal AEDs. All patients were routinely re-evaluated at least once a year, often more frequently, with follow-up averaging 7 years in the report from Ackerman and colleagues.

All this access to care and resources is unlikely to apply to other athletes, study authors and the editorialist agreed.

"In addition, many states still do not mandate the presence of a written Emergency Action Plan or automatic external defibrillators at all statewide high school athletic venues," Kim noted.

"Without the requirement and reliance on easily accessible automatic external defibrillators, how should this affect SDM outcomes in the context of sports eligibility? These are questions that are difficult to answer and humbly remind us of the pressing challenges presented by health care disparities, including within the sports cardiology space," he stressed.

Other limitations of the study included the possibility of survival or selection bias owing to a relatively small number of athletes who sought RTP approval after surviving a resuscitated SCD.

The investigators cited the ongoing Outcomes Registry for Cardiac Conditions in Athletes study as a source for better estimations of cardiac risk and more generalizable data on athletes who may be genetically predisposed to SCD.

This past weekend, National Football League safety Damar Hamlin returned in his first game back with the Buffalo Bills after recovering from his mid-game cardiac arrest in January. His case was attributed to commotio cordis, with no genetic anomaly publicly disclosed.

Comment