Competitive Sport Participation Among Athletes With Heart Disease
Authors: Aaron L. Baggish, Michael J. Ackerman, Rachel Lampert
Journal: Circulation (2017)

ore than 8 million young men and women participate in competitive high school or collegiate sports in the United States annually.For the vast majority of these young men and women, sport participation plays an invaluable role in promoting healthy physical, emotional, and cognitive development.In rare cases, however, seemingly healthy athletes with occult cardiovascular disease (CVD) die suddenly during sport participation.Strategies to reduce these highly visible tragedies, including preparticipation screening and medical oversight of training and competition, are well established and can lead to the identification of athletes with undiagnosed CVD.For the competitive athlete diagnosed with CVD, determination of future athletic eligibility is a critical step in a care continuum that begins with diagnosis and continues through long-term treatment.Fundamentally, eligibility determination is a quest to reduce the risk of future sudden death while simultaneously avoiding unnecessary sport restriction.This process may be challenging for the patient and family, clinicians, and schools or sporting organizations.Accordingly, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) provide eligibility recommendations for competitive athletes with established CVD.Until recently, the 2005 update of the 36th Bethesda Conference statement, an encyclopedic compendium of CVD diagnoses with binary yes-or-no eligibility recommendations for each diagnosis, served as the standard of care. 1 This binary approach to eligibility inherently facilitated paternalistic decision making, in which doctors, schools, and athletic organizations were encouraged/expected to permit or restrict sport participation with little or no input from the afflicted athlete (and parents).It is important to note that the right of a school to implement this guideline-centric model of paternalistic decision making was supported by the pivotal court ruling on Knapp versus Northwestern.In December 2015, a competitive sport eligibility statement that was sponsored jointly by ACC/AHA/HRS updated and replaced the 2005 Bethesda Conference. 2 This new document moves away from a binary approach to athletic eligibility and adopts the more nuanced and contemporary Class and Level of Evidence approach.Now used universally in cardiology professional society guidelines, this approach designates clinical strategies, in this case competitive athletic eligibility, as class I, recommended; class IIA and IIB indicating eligibility is reasonable or may be considered; and class III, not recommended.It is important to note that a number of CVD conditions including long-QT syndrome and the presence of an implantable cardiac defibrillator, for which competitive sports were previously considered strictly restricted, now carry class II recommendations.By definition, class II recommendations acknowledge clinical and scientific uncertainty, thereby providing clinicians and patients with an opportunity for flexible and individualized decision making.The potential impact of newly introduced class II recommendations is not trivial, because the AHA/ACC/HRS eligibility document now contains 84 class II Competitive Sport Participation Among Athletes With Heart DiseaseA Call for a Paradigm Shift in Decision Making