Arrhythmias in the Athlete: Evaluation, Treatment, and Return to Play

Publication Date: September 30, 2024
Last Updated: October 4, 2024

General Concepts and Principles

Clinical Considerations for Athletes With Arrhythmias

1. In athletes with symptoms of arrhythmias, clinical evaluation should include exercise history and history of performance-enhancing drugs (PEDs). (1, C-EO)
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2. In athletes with symptoms of arrhythmias, differential diagnosis should include consideration of etiologies specific to their sport. (1, C-EO)
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3. In athletes with symptoms of arrhythmias, evaluation should be performed by clinicians with an understanding of unique electrical and structural adaptations specific to the athlete (electrocardiogram [ECG] or cardiac structural) and of the differentiation of “grey zone” cardiac phenotypes. (1, C-EO)
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4. In athletes with symptoms of or concern for arrhythmias, exercise stress testing should be based on maximal effort and/or symptom reproduction rather than heart rate or protocol completion.

(1, C-EO)
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5. In athletes with symptoms of or concern for arrhythmias, exercise stress testing should be performed based on sport type and situation where symptoms are elicited.

(1, C-EO)
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6. In athletes with arrhythmogenic conditions returning to play, a stress test should be performed prior to return to play. (1, C-LD)
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7. In athletes with arrhythmias, clinical management strategies should consider limitations on athletic performance caused by the arrhythmia or by the pharmacological treatments for the arrhythmia, to optimize return to play if desired.

(1, C-EO)
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8. In athletes with arrhythmias, clinical management strategies should take into account athlete- and sport-specific considerations including impact of therapeutic options on timing of return to play and any sport-specific restrictions. (1, C-EO)
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9. In athletes with arrhythmias who are not returning to competitive sports, plans for other levels of exercise should be discussed. (1, C-EO)
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Shared Decision-making and Clinical Management Determination

1. In athletes with arrhythmogenic conditions, determination of clinical treatment options should be made through shared decision-making, prioritizing preferences, values, and goals of the athlete.

(1, C-LD)
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2. In athletes with arrhythmogenic conditions, the fundamentals of shared decision-making should be grounded in core principles of knowledge, humility, respect and trust, teamwork with key stakeholders, and transparent communication.

(1, C-EO)
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Emergency Action Planning for Sudden Cardiac Arrest

Emergency Action Planning

1. For athletes training or competing at schools, recreational facilities, or other athletic venues, an emergency action plan should be in place to respond to acute medical and cardiac events to improve survival from SCA.

(1, B-NR)
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2. For athletes training or competing at schools, recreational facilities, or other athletic venues, steps for rapid and early cardiopulmonary resuscitation (CPR) and defibrillation should be included in an emergency action plan (EAP) to improve survival from SCA.

(1, B-NR)
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3. For athletes competing at interscholastic levels or in other organized leagues, relevant governing bodies should put into place policies and direct resources toward increasing the effectiveness of EAPs. (1, B-NR)
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4. For athletes training or competing at schools, recreational facilities, or other athletic venues, there should be medical support and infrastructure that enables all athletes and team-affiliated staff to learn cardiopulmonary resuscitation and be familiar with automated emergency defibrillators (AEDs). (1, B-NR)
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Sudden Cardiac Arrest in Athletes

Sudden Cardiac Arrest Prevention Strategies

1. In athletes, periodic preparticipation evaluations including screening for SCD risk is recommended.

(1, C-EO)
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Emergency Action Plan for and Immediate Treatment of Sudden Cardiac Arrest

1. In athletes who have collapsed and are nonresponsive, SCA should be presumed and acted upon until proven otherwise.

(1, B-NR)
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2. For athletes with a known SCA-predisposing heart condition who are returning to play, an individualized EAP should be in place.

(1, C-EO)
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3. In athletes with a known SCA-predisposing heart condition (and/or their families), obtaining and carrying a personal AED with their personal athletic equipment may be considered as part of their EAP made via shared decision-making. (2b, C-EO)
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Sudden Cardiac Arrest Treatment and Implantable Cardioverter-Defibrillator Management in Athletes

1. In athletes who have experienced SCA, a comprehensive evaluation and shared decision-making discussion of potential risks of sports participation with an expert provider is recommended.

(1, C-EO)
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2. In athletes who have experienced SCA, further evaluation including addressing psychological readiness should be completed prior to return to play. (1, C-EO)
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3. In athletes who have experienced SCA, an ICD should be implanted as indicated based on underlying disease entity.

(1, A)
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4. In athletes with an ICD, return to play is reasonable, in the context of shared decision-making that includes underlying disease entity, clinical characteristics, and sport type.

(2a, B-NR)
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5. In athletes who have experienced SCA and are undergoing ICD implant, it is reasonable to consider sport type and disease entity in the decision regarding ICD type and location.

(2a, B-NR)
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6. For athletes undergoing ICD implantation who will be returning to play, a waiting period of 4–6 weeks after a new implant or 2 weeks after generator replacement is reasonable.

(2a, C-EO)
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7. In athletes who have experienced SCA and have an ICD, ICD detection criteria should be programmed to long duration and a high rate cutoff to prevent unnecessary shocks.

(1, B-NR)
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8. In athletes who have experienced SCA, exercise stress testing at maximum effort should be performed to measure heart rate, assess for arrhythmias during exertion, and confirm appropriate sensing by the ICD (if applicable) prior to return to vigorous exercise. (1, C-EO)
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9. In athletes who have experienced SCA, an individualized EAP should be in place prior to return to play. (1, C-EO)
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10. In athletes who have experienced SCA, regular electrophysiology (EP) follow-up is recommended, including remote monitoring of ICDs (if applicable).

(1, A)
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11. In athletes with an ICD who experience an ICD shock, an evaluation of the cause, treatment of the underlying etiology, and confirmation of appropriate device function should be done prior to return to play. (1, C-EO)
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Commotio Cordis

Commotio Cordis Prevention and Diagnosis

1. In athletes who have experienced SCA with a history of blow to the chest, underlying heart disease should be excluded prior to diagnosing commotio cordis.

(1, C-EO)
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2. For athletes participating in sports for which chest protectors are used, chest protectors should meet sports- and position-appropriate standards.

(1, C-EO)
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3. In athletes under age 13 years, the use of age-appropriate safety baseballs is reasonable to reduce the risk of commotio cordis.

(2a, C-EO)
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Symptoms of Arrhythmias in Athletes

Syncope in Athletes
Etiologies (Noncardiac Differential)

Diagnostic and Monitoring Strategies for Syncope in Athletes

1. In athletes with syncope, a detailed history and physical examination should be performed to guide further diagnostic evaluation. (1, B-NR)
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2. In all athletes with syncope during exertion, an ECG, exercise stress test, and transthoracic echocardiogram should be performed.

(1, B-NR)
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3. In athletes with syncope during exertion with high-risk features, withholding from sports participation pending evaluation is indicated. (1, C-EO)
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4. In athletes with syncope during exertion with high-risk features and with negative primary evaluation, advanced imaging should be performed.

(1, B-NR)
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5. In athletes with syncope, tests should be interpreted in the context of exercise-induced cardiac remodeling (EICR). (1, C-EO)
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6. In athletes with unexplained syncope or when arrhythmic syncope is suspected, ambulatory ECG monitoring is beneficial.

(1, B-R)
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7. In athletes with a high suspicion of arrhythmic etiology, unexplained after initial testing, and/or whose symptoms are rare, loop recorder implantation can be useful.

(2a, B-NR)
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8. In athletes with syncope with high-risk features and negative initial evaluation, an EP study may be considered. (2b, C-LD)
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9. In athletes with syncope, tilt table testing is not recommended because of high prevalence of false positives leading to inappropriate interventions.

(3 - Harm, C-LD)
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10. In athletes with a history suggestive of noncardiac syncope, further evaluation is not indicated.

(3 - No Benefit, C-EO)
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Treatment of Neurally Mediated or Orthostatic Syncope in Athletes

1. In athletes with neurally mediated or orthostatic syncope, providing education on the diagnosis, nonpharmacological treatment, prognosis, and triggers of syncope is recommended.

(1, C-EO)
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2. In athletes with neurally mediated or orthostatic syncope, communication among the medical and athletic teams for preparation to manage a syncopal event is recommended. (1, C-EO)
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Palpitations in Athletes

1. In athletes with palpitations, a history, physical examination, and resting 12-lead ECG are recommended. (1, B-NR)
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2. In athletes with palpitations associated with exercise, exercise stress testing should be performed to mimic the athlete’s sport, or monitoring during exercise should be performed.

(1, B-NR)
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3. For athletes in a team setting, supplying athletic trainers with be useful. (2a, B-NR)
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4. In athletes with palpitations, a personal (portable or wearable) ECG may be considered as a diagnostic tool.

(2b, C-LD)
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Ventricular Arrhythmias

Evaluation of Ventricular Arrhythmias in Athletes

1. In athletes with symptoms suspicious for ventricular arrhythmias, a resting 12-lead ECG and ambulatory ECG monitor are recommended to assess ventricular arrhythmia burden and complexity. (1, B-NR)
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2. In athletes with symptoms suspicious for suspected ventricular arrhythmias, exercise stress testing is reasonable to assess ventricular arrhythmia occurrence, characteristics, and morphology. (2a, B-NR)
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3. In athletes with ventricular arrhythmias, taking a history of supplements and performance-enhancing drug use is recommended to identify potential triggers for ventricular arrhythmias.

(1, C-EO)
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4. In athletes with 2 or more asymptomatic typical PVCs, or 1 atypical PVC, on a 12-lead ECG, further evaluation with ambulatory monitoring and cardiac imaging is recommended.

(1, C-LD)
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5. In athletes with 1 asymptomatic typical PVC (single outflow tract or fascicular morphology) on a 12-lead ECG, further evaluation may be considered.

(2b, C-EO)
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6. In athletes with PVCs of a single outflow tract or fascicular morphology, assessment of cardiac structure and function with echocardiography is recommended to exclude underlying pathology.

(1, C-EO)
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7. In athletes with higher-risk ventricular arrhythmias and/or abnormal primary testing, comprehensive cardiac imaging including cardiac magnetic resonance imaging (CMR) and exercise stress testing is recommended to assess for underlying structural heart disease (SHD) and behavior of PVCs with exercise. (1, B-NR)
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8. In adult athletes with ventricular arrhythmias with higher-risk but nondiagnostic features after comprehensive examination, EP study with voltage mapping may be useful in defining the extent and location of the arrhythmogenic substrate.

(2b, C-LD)
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9. In athletes with ventricular arrhythmias with higher-risk features, withholding from sports participation pending evaluation is recommended. (1, C-EO)
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Treatment of Ventricular Arrhythmias in the Athlete

Treatment of Benign Ventricular Arrhythmias in the Athlete

1. In athletes with symptomatic benign ventricular arrhythmias, risk factor management, including

avoidance of performance-enhancing or illicit drugs,

(1, C-EO)
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weight loss, (1, C-EO)
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treatment of obstructive sleep apnea,

(1, B-R)
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smoking cessation,

(1, C-EO)
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alcohol avoidance, (1, C-EO)
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caffeine avoidance,

(1, B-R)
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and hypertension management,

(1, C-EO)
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as well as reassurance

(1, C-EO)
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is recommended.

2. In the asymptomatic athlete with benign ventricular arrhythmias, observation is recommended.

(1, C-EO)
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3. In the asymptomatic athlete with a high burden of benign PVCs (>10% burden) in the absence of structural heart disease, active monitoring for PVC-induced cardiomyopathy with serial imaging and ambulatory monitoring is recommended. (1, C-LD)
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4. In athletes with symptomatic benign ventricular arrhythmias desiring treatment, catheter ablation is useful as first-line therapy, or if antiarrhythmic drugs (AADs) are contraindicated or poorly tolerated. (1, B-R)
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5. In athletes with symptomatic benign ventricular arrhythmias, a trial of medical therapy with beta blockers or calcium channel blockers is reasonable.

(2a, B-R)
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6. In athletes with symptomatic benign ventricular arrhythmias, antiarrhythmic drug therapy with class IC agents is reasonable. (2a, B-R)
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7. In athletes with benign ventricular arrhythmias, stress testing after treatment with either ablation or medications can be useful to determine arrhythmia suppression.

(2a, C-EO)
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Treatment of Complex Ventricular Arrhythmias in the Athlete

Complex Ventricular Arrhythmias

1. In the athlete with complex ventricular arrhythmias, management based on underlying pathology is recommended, with consideration of treatment impact on exercise performance, and shared decision-making to individualize treatment strategy.

(1, C-EO)
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2. In athletes who have survived sustained ventricular tachycardia in the absence of a reversible cause, an ICD is recommended, based on underlying pathology.

(1, A)
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3. In athletes with monomorphic ventricular arrhythmias with underlying structural heart disease including inherited entities and coronary artery disease, catheter ablation for arrhythmia suppression is useful as first-line therapy or when antiarrhythmic drug therapy is contraindicated or has failed. (1, B-NR)
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4. In athletes with VF triggered by monomorphic PVCs, catheter ablation is recommended. (1, B-NR)
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5. In athletes with complex ventricular arrhythmias, documentation of suppression of arrhythmias with a maximal exercise stress test is recommended prior to return to play. (1, C-EO)
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6. In athletes with suspected PVC-induced cardiomyopathy, catheter ablation is useful as first-line therapy or when antiarrhythmic drug therapy is contraindicated or has failed regardless of symptoms.

(1, B-NR)
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7. In athletes with suspected PVC-induced cardiomyopathy, medical therapy (antiarrhythmic drug therapy, as well as guideline-directed medical therapy [GDMT] for decreased ejection fraction) is reasonable to improve left ventricular function regardless of symptoms. (2a, B-NR)
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8. In athletes with ventricular arrhythmias and nonfamilial and/or genotype-negative phenotype-positive ARVC (presumed exercised induced), catheter ablation and/or ICD is reasonable after appropriate risk stratification.

(2a, C-LD)
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9. In athletes with ventricular arrhythmias and nonfamilial and/or genotype-negative phenotype-positive ARVC (presumed exercised induced), continuation of vigorous endurance sports is harmful. (3 - Harm, B-NR)
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Inherited Arrhythmias and Cardiomyopathies

Athletes with Inherited Arrhythmia Syndromes

1. In athletes with inherited arrhythmia syndromes (IAS), an assessment by an expert in genetic cardiology and a shared decision-making model of care is recommended. (1, C-LD)
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2. In athletes with a positive genetic test for IAS, comprehensive assessment and cardiac testing are recommended to determine the risk category. (1, B-NR)
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3. In athletes with LQTS or CPVT in whom beta blocker therapy leads to decreased performance in their sport and/or subsequent quality-of-life issues, left cardiac sympathetic denervation (LCSD) can be effective.

(2a, B-NR)
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4. In athletes with IAS who have received a clinically indicated ICD, sports participation is reasonable.

(2a, B-NR)
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5. In athletes with IAS, ICD implantation for the sole purpose of return to play is potentially harmful and should not be done.

(3 - Harm, C-LD)
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Athletes With Long QT Syndrome

1. In athletes with LQTS under expert assessment and supervision, return to play is reasonable in a shared decision-making model after risk assessment, education, and initiation of appropriate therapies.

(2a, B-NR)
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2. In athletes with LQTS, review and/or cessation of medications known to prolong the QT interval is recommended, and whenever possible, prevention and correction of electrolyte disturbances are recommended. (1, B-NR)
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3. In athletes with asymptomatic LQTS and a normal corrected QT interval (concealed variant-positive LQTS), initiation of QT-related preventative measures is recommended prior to return to play.

(1, B-NR)
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4. In athletes with asymptomatic LQTS and a corrected QT interval <470 ms, therapy with beta blockers can be useful. (2a, B-NR)
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5. In athletes with LQTS with symptoms and/or a corrected QT interval >470 ms, guideline-directed and genotype/patient-tailored therapy with medications, LCSD, and/or device therapy should be optimized fully before return to play.

(1, B-NR)
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6. In athletes with LQTS on beta blocker therapy, nonselective beta blockers (especially nadolol and propranolol) are recommended, with dosing tailored to the patient’s risk profile and response to therapy. (1, B-NR)
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7. For athletes with LQTS and severe bradycardia, other treatment configurations besides beta blockers (eg, alternative medical therapy, LCSD, and device therapy) are reasonable.

(2a, B-NR)
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8. In athletes with LQTS (including type 1), participation in swimming/diving is reasonable with appropriate precautions. (2a, B-NR)
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9. In athletes with LQTS who are unable to tolerate beta blockers or who have ongoing events on beta blockers, treatment intensification with medication, LCSD, and/or device therapy should be done and reoptimized fully prior to return to play.

(1, B-NR)
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Catecholaminergic Polymorphic Ventricular Tachycardia

Athletes With Catecholaminergic Polymorphic Ventricular Tachycardia

1. In athletes with asymptomatic CPVT and a negative exercise stress test (genotype-positive phenotype-negative), return to play is recommended with discussion of prophylactic CPVT-directed medical therapy.

(1, C-LD)
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3. In athletes with previously symptomatic CPVT while not on therapy, return to play may be considered after establishing and confirming appropriate therapy.

(2b, C-LD)
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4. In athletes with previously symptomatic CPVT for whom return to play is being considered, combination therapy with beta blocker and flecainide, and consideration of triple therapy with LCSD, is recommended before return to play, with a goal of optimizing therapy to normalize the exercise stress test.

(1, C-LD)
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5. In athletes with ongoing symptomatic CPVT despite establishment of dual or triple therapy, return to play is potentially harmful. (3 - Harm, C-EO)
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Brugada Syndrome

Athletes With Brugada Syndrome

1. In athletes with Brugada syndrome, avoidance of arrhythmia triggers including sodium-channel blocking drugs, alcohol, and heavy meals is recommended.

(1, B-NR)
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2. In athletes with Brugada syndrome,
aggressive treatment of fever (1, C-LD)
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and avoidance of hyperthermia

(1, C-EO)
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are recommended, including taking precautions to prevent overheating particularly for prolonged endurance exercise in warm climates

Short QT Syndrome

Athletes With Short QT Syndrome

1. In athletes with SQTS, patient education about the importance of fluid and electrolyte balance during endurance exercise is recommended.

(1, C-EO)
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2. In athletes with symptomatic SQTS and/or a QTc <320 ms, treatment with quinidine can be beneficial.

(2a, C-LD)
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Athletes With Inherited Cardiomyopathies

Treatment and Management of Athletes With Inherited Cardiomyopathies Before and After Return to Play

1. In athletes with inherited cardiomyopathies, expert assessment by clinician(s) with genetic and sports cardiology experience and a shared decision-making model of care is recommended.

(1, B-NR)
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2. In athletes with inherited cardiomyopathies, genetic testing is recommended.

(1, B-NR)
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3. In athletes with inherited cardiomyopathies considering return to play, or returning to play after arrhythmia treatment, a maximal stress test is recommended to identify exercise-induced ventricular arrhythmias.

(1, C-LD)
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4. In athletes with inherited cardiomyopathies, an ICD should not be implanted solely to facilitate return to play. (3 - Harm, B-NR)
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Treatment and Management for Athletes With Hypertrophic Cardiomyopathy

Treatment and Management Specific to Athletes With Hypertrophic Cardiomyopathy

1. In athletes with genotype-positive phenotype-negative HCM, return to play in conjunction with expert assessment is recommended.

(1, B-NR)
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2. In young athletes with HCM who return to play, close follow-up with regular reassessment and ongoing risk stratification is recommended due to risk of evolution of their phenotype, including in those who are genotype-positive phenotype-negative.

(1, B-NR)
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3. In athletes with phenotype-positive HCM, participation in competitive sports is reasonable with appropriate therapy and EAP including access to an AED.

(2a, B-NR)
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4. In athletes with symptomatic obstructive HCM, intentional measures to attenuate the left ventricular obstruction are recommended before return to play. (1, B-NR)
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Management Specific to Athletes With Arrhythmogenic and Dilated Cardiomyopathies

1. In athletes with genotype-positive phenotype-negative ACM, genotype-informed discussion with the athlete around the potential associations between high-intensity endurance exercise and increased likelihood of developing overt ACM phenotype and ventricular arrhythmias is recommended.

(1, B-NR)
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2. In athletes with genotype-positive but phenotype-negative ACM, sports participation should be tailored to patient’s genotype and the intensity and duration of sport. (1, B-NR)
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3. In athletes with phenotype-positive ACM, sports participation should be tailored to patient’s genotype and the intensity and duration of sport.

(1, B-NR)
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4. In athletes with phenotype-positive ACM and a lower-risk genotype, participation in vigorous endurance sports may be considered. (2b, C-LD)
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5. In athletes with phenotype-positive ACM and higher-risk genotypes, participation in vigorous endurance sports is potentially harmful.

(3 - Harm, B-NR)
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6. In athletes with nonfamilial and/or genotype-negative phenotype-positive ARVC (presumed exercised induced), continuation of vigorous endurance sports is harmful. (3 - Harm, B-NR)
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7. In athletes with DCM who are asymptomatic with left ventricular ejection fraction (LVEF) >45% and no high-risk clinical features, return to play following expert assessment and commencement of medical therapy is reasonable.

(2a, B-NR)
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8. In athletes with DCM who are asymptomatic with LVEF <45% who have been appropriately risk assessed and risk treated, return to play may be considered.

(2b, C-LD)
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Moving From Athlete to Family: Implications of a Genetic Diagnosis

1. In athletes with suspected genetic heart disease, family history including 3 generations on both sides of the family is recommended.

(1, B-NR)
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2. In athletes with suspected genetic heart disease based on family history and/or phenotype, consultation with (or referral to) a multidisciplinary team with expertise in genetic heart disease is recommended.

(1, B-NR)
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3. In athletes with genetic heart disease who have a positive genetic test, variant-specific, predictive cascade testing in the appropriate family members is recommended in conjunction with genetic counseling. (1, B-NR)
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4. In the absence of genetic testing or when the athlete has a negative test result for a genetic heart disease, first-degree relatives should undergo clinical screening including ECG and echocardiogram as minimum baseline investigations.

(1, B-NR)
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5. In athletes with a genetic variant but without phenotypic expression of the disease, counseling about return to play should be disease- and variant-specific.

(1, B-NR)
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6. Athletes with a genetic variant for arrhythmogenic conditions should not be restricted from play by governing bodies based on genetic results alone.

(3 - Harm, B-NR)
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Atrial Fibrillation

Atrial Fibrillation Evaluation in Athletes

1. In athletes with symptoms or personal ECG (portable wearable) findings concerning for atrial fibrillation (AF,) electrocardiographic documentation is recommended to establish a diagnosis of AF.

(1, C-LD)
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2. In athletes with AF, a detailed history and physical examination focused on identifying reversible or modifiable factors as well as exercise history should be performed. (1, C-LD)
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3. In athletes with AF, initial evaluation should include 12-lead ECG, transthoracic echocardiogram, and laboratory evaluation. (1, C-LD)
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4. In athletes with AF, rhythm monitoring can be useful to evaluate burden, rate of ventricular response during an episode, relationship to symptoms, and documentation of other arrhythmias.

(2a, C-LD)
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5. In young and young adult athletes with AF, advanced imaging such as CMR is reasonable.

(2a, C-LD)
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6. In young and young adult athletes with AF and clinical suspicion of channelopathy or cardiomyopathy, genetic testing is reasonable.

(2a, B-NR)
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7. In young and young adult athletes with AF, genetic testing may be considered. (2b, B-NR)
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8. In young and young adult athletes with AF, withholding from sports participation pending evaluation of malignant etiologies is recommended.

(1, C-EO)
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9. In athletes with AF, recommendations regarding intensive endurance sports participation while evaluation is ongoing should take into consideration symptoms, heart rate, and pattern of AF.

(1, C-EO)
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10. In athletes with AF, it is reasonable for patient counseling to clarify that sports-related AF is not life-threatening and sports participation is guided by symptoms.

(2a, C-EO)
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11. Athletes with AF should be managed in a center with expertise in both AF and the care of athletes.

(1, B-NR)
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Treatment of AF in Athletes

Risk Factor Modification in Athletes With AF

1. In athletes with AF, risk factor management, including weight loss, treatment of obstructive sleep apnea, alcohol avoidance, and hypertension management is recommended. (1, B-R)
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2. In athletes with AF who engage in long-term, high-intensity endurance training, exercise detraining with modification to low to moderate levels of exercise may be considered. (2b, C-LD)
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Prevention of Thromboembolism in Athletes With AF

1. For athletes with nonvalvular AF, stroke risk assessment using a validated risk score, such as CHA2DS2-VASc, or other disease-specific factors is recommended.

(1, B-NR)
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2. For athletes with nonvalvular AF with an estimated annual thromboembolic risk of ≥2% per year (CHA2DS2-VASc score of ≥2 in men or ≥3 in women, or other disease-specific factors), oral anticoagulation (OAC) is recommended.

(1, A)
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3. In athletes with AF on anticoagulation who are participating in sports with a risk of trauma, a shared decision-making discussion about continued participation is recommended.

(1, C-EO)
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4. In athletes with AF, left atrial appendage occlusion (LAAO) may be considered based on anticoagulation indication and bleeding risk, taking into account patient preference to avoid long-term anticoagulation, in a shared decision-making context. (2b, B-NR)
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5. In athletes meeting anticoagulation criteria who wish to temporarily participate in sports with a high risk of bleeding, temporarily withholding anticoagulation may be considered with a shared decision-making discussion.

(2b, C-EO)
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Rate and Rhythm Control in Athletes With AF

1. For symptomatic athletes, maintenance of sinus rhythm is recommended to improve

quality of life

(1, A)
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and exercise performance (1, B-NR)
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2. In athletes with symptomatic AF, catheter ablation is recommended as first-line therapy, or if antiarrhythmic drugs are contraindicated or poorly tolerated.

(1, B-R)
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3. In athletes undergoing catheter ablation for AF, in whom typical atrial flutter has been previously documented or induced during an EP study, cavotricuspid isthmus (CTI) ablation is recommended.

(1, A)
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4. In athletes with AF and rapid ventricular rate, control of ventricular rate using a beta blocker or nondihydropyridine calcium channel blocker is recommended after consideration of impact on exercise performance and resting heart rate.

(1, C-EO)
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5. In athletes with symptomatic paroxysmal AF undergoing ablation without a documented arrhythmia trigger, a pulmonary vein isolation- (PVI) only approach is recommended. (1, B-R)
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6. In athletes with infrequent, symptomatic paroxysmal AF, antiarrhythmic drug therapy (with flecainide or propafenone with the addition of a beta blocker or nondihydropyridine calcium channel blocker) is reasonable as a “pill-in-the-pocket” approach if drug therapy is preferred.

(2a, A)
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7. In young and young adult athletes with AF, an EP study is reasonable to evaluate an accessory pathway (AP) or predisposing arrhythmias such as atrial flutter or paroxysmal supraventricular tachycardia (SVT), for ablation either as a stand-alone procedure or as part of a planned PVI.

(2a, B-NR)
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8. In athletes with AF, antiarrhythmic drug therapy with flecainide or propafenone with the addition of a beta blocker or nondihydropyridine calcium channel blocker may be considered as a daily medication if drug therapy is preferred. (2b, C-LD)
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9. In athletes with AF, catheter ablation to restore sinus rhythm with the sole intent of eliminating the need for long-term anticoagulation should not be performed.

(3 - Harm, B-R)
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Wolff-Parkinson-White Pattern and Syndrome

WPW pattern: The term “WPW pattern” refers to patients with preexcitation manifest on an ECG in the absence of symptoms.

WPW syndrome: The term “WPW syndrome” refers to patients with both preexcitation manifest on an ECG and symptomatic arrhythmias involving the AP.

Evaluation of Athletes With Wolff-Parkinson-White Pattern or Syndrome

1. In athletes with a WPW pattern on ECG, cardiac evaluation including physical examination, family history, and echocardiography at diagnosis is recommended whether symptoms are present or absent. (1, C-LD)
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2. In athletes with a WPW pattern and no symptoms, return to play during evaluation and pending treatment is recommended.

(1, C-LD)
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3. In athletes with a WPW pattern, regardless of symptoms, shared decision-making among patients, families, and their electrophysiologist is recommended regarding catheter ablation and/or EP studies, which includes a discussion of procedural risks, benefits, AP recurrences after ablation, and limitations of risk stratification tools. (1, C-EO)
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4. In athletes with a right anteroseptal WPW pattern on ECG, pharmacologic testing with intravenous adenosine and/or an EP study should be performed to rule out a fasciculoventricular pathway before attempting catheter ablation, as fasciculoventricular pathways do not participate in the atrioventricular reciprocating tachycardia (AVRT) circuit and are not associated with rapid antegrade conduction.

(1, C-LD)
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5. In athletes with a WPW pattern who either choose not to have an ablation or have an unsuccessful ablation, periodic cardiology follow-up is recommended regardless of symptoms. (1, C-LD)
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6. In athletes with WPW pattern or syndrome who have had a catheter ablation, periodic cardiology follow-up is recommended for at least 1 year post-procedure to evaluate for AP recurrence.

(1, C-LD)
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Treatment of Athletes With Wolff-Parkinson-White

1. In athletes with a WPW pattern on ECG and symptomatic or documented arrhythmias, catheter ablation of AP(s) is recommended to manage the symptoms caused by the arrhythmia and reduce the risk of life-threatening events (LTEs).

(1, B-NR)
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2. In athletes with a WPW pattern on ECG and left ventricular dysfunction attributed to left ventricular dyssynchrony, catheter ablation of AP(s) is recommended to improve left ventricular remodeling and left ventricular function regardless of anterograde characteristics of the AP(s). (1, C-LD)
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3. In young athletes (aged <18 years) with a persistent WPW pattern on the ECG, an EP study is recommended to identify high-riska AP(s) properties.

(1, B-NR)
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4. In young athletes (aged <18 years) with an intermittent WPW pattern on the ECG, an EP study is reasonable to identify high-riska AP(s) properties.

(2a, C-LD)
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5. In young adult and adult athletes (aged ≥18 years) with a persistent WPW pattern on the ECG, an EP study is reasonable to identify high-riska AP(s) properties.

(2a, B-NR)
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6. In young adult and adult athletes (aged ≥18 years) with an intermittent WPW pattern on the ECG, an EP study may be considered to identify high-riska AP(s) properties.

(2b, B-NR)
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7. In athletes with a WPW pattern on ECG and ≥1 high-risk propertiesa present during the EP study, catheter ablation of AP(s) is recommended to prevent LTEs. (1, B-NR)
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8. In athletes with a WPW pattern on ECG and without high-risk propertiesa identified on EP testing, catheter ablation of AP(s) is reasonable.

(2a, C-LD)
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9. In athletes with a WPW pattern on ECG undergoing ablation, cryoablation is reasonable in those with anteroseptal and midseptal AP(s) to reduce the risk of permanent injury to the conduction system.

(2a, C-LD)
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10. In athletes with a WPW pattern on ECG found to be due to fasciculoventricular pathway, catheter ablation should not be performed due to potential harm to the conduction system.

(3 - Harm, C-LD)
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a High-risk markers: spontaneous or inducible SVT, accessory pathway effective refractory period (APERP) ≤250 ms, shortest preexcited R-R interval (SPERRI) ≤250 ms, multiple APs.

Bradycardia and Pacemakers

Athletes With Bradycardia

1. For athletes with significant distal conduction disease, including left bundle branch block, bifascicular block, or complete heart block at any level, evaluation prior to return to play is recommended.

(1, B-NR)
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2. In athletes with significant sinus and/or AV node disease that does not correct with light exercise, further evaluation during return to play is reasonable.

(2a, C-EO)
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3. In athletes with asymptomatic sinus node slowing or first-degree heart block/second-degree Mobitz type I AV block (Wenckebach) at rest, further evaluation is not recommended because these are expected adaptations to training

(3 - No Benefit, B-NR)
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Athletes With a Pacemaker

1. In athletes with a pacemaker and without exercise-limiting underlying conditions, return to play is recommended.

(1, C-LD)
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2. For athletes who are completely pacemaker-dependent, collision sports may be considered after a shared decision-making discussion of the potential risks and the absence of data on safety. (2b, C-EO)
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3. For athletes undergoing permanent pacemaker (PPM) implantation, consideration for cardiac physiological pacing to reduce symptoms from right ventricular pacing and the risk of pacing-induced cardiomyopathy should be based on characteristics including ejection fraction, pacing burden, and QRS morphology.

(1, C-LD)
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4. For athletes undergoing pacemaker implantation who will be returning to play, a waiting period of 4–6 weeks after a new transvenous implant, or 2 weeks after leadless implant or generator replacement, is reasonable. (2a, C-EO)
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5. For athletes with a pacemaker and AV block, programming rate-adaptive AV delay and post-ventricular atrial refractory period shortening should be performed to prevent pacemaker Wenckebach or 2:1 conduction at high sinus rates.

(1, C-LD)
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6. For athletes with a pacemaker and sinus node dysfunction, programming should be optimized to avoid right ventricular pacing.

(1, B-NR)
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7. For a young or young adult athlete undergoing pacemaker implant, it should be confirmed that the device programming options allow age-appropriate heart rates. (1, C-EO)
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8. For athletes with sinus node dysfunction and a permanent pacemaker, an exercise stress test with the appropriate modality based on the type of sport and the environment in which symptoms are elicited should be performed for programming of rate-response and other exercise-related parameters.

(1, C-LD)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Arrhythmias in the Athlete: Evaluation, Treatment, and Return to Play

Authoring Organization

Heart Rhythm Society

Publication Month/Year

September 30, 2024

Last Updated Month/Year

October 4, 2024

Document Type

Consensus

Country of Publication

US

Document Objectives

The overarching goal of this document is to provide evidence-based and expert consensus recommendations on the diagnosis, treatment, and management of arrhythmias in athletes of all ages, with an emphasis on shared decisionmaking.

Target Patient Population

Athletes of all ages

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital, Outpatient, School

Intended Users

Genetics, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Diagnosis, Assessment and screening, Treatment, Management, Prevention, Rehabilitation

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation, D001919 - Bradycardia, D016757 - Death, Sudden, Cardiac, D013575 - Syncope, D019462 - Syncope, Vasovagal, D013610 - Tachycardia, D009203 - Myocardial Infarction, D006330 - Heart Defects, Congenital, D054537 - Atrioventricular Block, D014927 - Wolff-Parkinson-White Syndrome, D001145 - Arrhythmias, Cardiac, D002313 - Cardiomyopathy, Restrictive, D006359 - Heat Exhaustion, D002312 - Cardiomyopathy, Hypertrophic, D014693 - Ventricular Fibrillation, D009202 - Cardiomyopathies, D001146 - Arrhythmia, Sinus, D016170 - Accelerated Idioventricular Rhythm, D018880 - Atrial Premature Complexes, D005117 - Cardiac Complexes, Premature, D013616 - Tachycardia, Sinus, D006327 - Heart Block, D017379 - Hypertrophy, Left Ventricular, D053840 - Brugada Syndrome, D008133 - Long QT Syndrome, D018882 - Heat Stress Disorders, D002346 - Carotid Sinus, D018879 - Ventricular Premature Complexes, D002311 - Cardiomyopathy, Dilated, D024741 - Cardiomyopathy, Hypertrophic, Familial

Keywords

atrial fibrillation, exercise, arrhythmogenic right ventricular cardiomyopathy, arrhythmogenic left ventricular cardiomyopathy, ventricular arrhythmias, antiarrhythmic drug therapy, athletes, genetic arrhythmias, implantable and external cardioverter devices, premature ventricular beats, sudden cardiac arrest, ventricular fibrillation, ventricular tachycardia, ventricular assist device, pacemaker, supraventricular tachycardia (SVT), ablation, atrioventricular block, arrhythmias, bradyarrhythmia, Supraventricular Arrhythmias, arrhythmia, Competitive Athletes, arrhythmic risk, non-sustained ventricular tachycardia, Left ventricular septal pacing, Left Ventricular Assist Devices, sports cardiology, athlete, return to play, shared decision-making, emergency action plan, defibrillation, complex arrhythmias, antiarrhythmic medications, Exercise stress testing, Wolff-Parkinson-White pattern

Source Citation

Lampert R, Chung EH, Ackerman MJ, Arroyo AR, Darden D, Deo R, Dolan J, Etheridge SP, Gray BR, Harmon KG, James CA, Kim JH, Krahn AD, La Gerche A, Link MS, MacIntyre C, Mont L, Salerno JC, Shah MJ, 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play, Heart Rhythm (2024), doi: https://doi.org/10.1016/j.hrthm.2024.05.018.