Return-to-Play for Athletes With Genetic Heart Diseases
Authors: Kari L. Turkowski, J. Martijn Bos, Nicholas C. Ackerman, Ram K. Rohatgi, Michael J. Ackerman
Journal: Circulation (2018)

◼ hypertrophic cardiomyopathy ◼ long QT syndrome ◼ shared decision making U ntil recently, expert guidelines such as the 2005 36th Bethesda Conference Guidelines 1 and the 2005 European Society of Cardiology 2 guidelines have recommended disqualification from most competitive sports for athletes with a variety of genetic heart diseases, aiming to prevent sudden cardiac death.However, recent studies have shown that carefully selected athletes with a variety of genetic heart diseases, including catecholaminergic polymorphic ventricular tachycardia and long QT syndrome, who elected to continue in competitive sports after a shared decision-making evaluation rarely experienced disease-triggered breakthrough cardiac events. 3-5These observations have prompted acknowledgment of the importance of shared decision making and consideration of an athlete's desire to return-to-play in the recent 2015 American Heart Association/ American College of Cardiology scientific statement. 5This document recognized that the foundational evidence to compel a recommendation for disqualification was disease-dependent and, in many instances, lacking. 5It updated the Bethesda guidelines by defining return-to-play as an approval from an expert who specializes in genetic heart diseases to participate in competitive sports after a thorough examination and a comprehensive treatment/management plan has been established.Additionally, the statement advised disclosure of the athlete's medical condition to the athlete's school/university with no guarantee that the host institution will uphold the return-to-play decision. 5 After approval by the Mayo Clinic Institutional Review Board, a retrospective analysis was performed for all competitive athletes with the diagnosis of a genetic heart disease evaluated at Mayo Clinic's Genetic Heart Rhythm Clinic from July 2000 to December 2015 through review of their electronic medical records, with the goal of determining return-to-play and breakthrough cardiac event outcomes as well as frequency of and reasons for participation denials.Decisions on return-to-play denial were usually obtained during follow-up visits or received via personal communication.When necessary, contact was made with the institution/ organization to further clarify reasons for denial.A breakthrough cardiac event was defined as cardiogenic syncope/seizures, documented ventricular arrhythmias, aborted cardiac arrest, appropriate ventricular tachycardia-or ventricular fibrillation-terminating implantable cardioverter defibrillator shocks, and sudden cardiac death that occurred while treated and after the patient had been given approval to return-to-play.All breakthrough cardiac events that occurred in our study subjects were evaluated by an expert (M.J.A.) to determine whether the event was caused by the underlying genetic heart disease.Overall, 366 athletes (206 male [56%]) were evaluated (Figure [A]).After their evaluation, 44 patients (12%) chose to self-disqualify from athletic activity.After establishing their comprehensive treatment program, only 9/322 athletes (3%) experienced a nonlethal breakthrough cardiac event (4 of which occurred outside of sports) in 961 combined athlete-