Arrhythmias in the Athlete: Evaluation, Treatment, and Return to Play
Introduction
Introduction
Top 10 Take-Home Messages
- For many arrhythmogenic disease entities, current data in athletes, while often not large enough to be definitive, have not confirmed increased arrhythmic risk of continuing sports participation for athletes who are appropriately risk-assessed and treated, and thus the approach to return to play (RTP) is one of individualized shared decision-making (SDM).
- The overarching goal in caring for athletes should be facilitating the athlete’s return to sport if this is the desired outcome, through appropriate risk assessment and athlete-focused management of their arrhythmic condition. Restriction from sport is not benign.
- Both venue-based and individualized emergency action plans (EAPs) including plans for early defibrillation are critical to survival of athletes with sudden cardiac arrest (SCA).
- Disease-specific and guideline-based risk assessment and treatment of arrhythmogenic conditions prior to return to play is critical.
- For patients with underlying complex arrhythmias, appropriate strategies for sudden death prevention and arrhythmia suppression are needed prior to return to play, including confirmation of suppression of arrhythmia during exercise.
- Treatment decisions—including those regarding antiarrhythmic medications, ablation, and devices—should take athletic performance and training into consideration.
- Exercise stress testing in athletes for diagnostic purposes or defining therapeutic efficacy should mimic the athlete’s sport where possible and be terminated based on maximal effort, symptoms, and/or documentation of arrhythmia.
- Endurance exercise in particular may contribute to arrhythmogenic conditions such as atrial fibrillation and genotype-negative arrhythmogenic right ventricular cardiomyopathy (ARVC); risks and benefits of continued participation in endurance sports should be carefully weighed in athletes with these conditions.
- The choice of pacemaker or defibrillator form factor and programming parameters should take into consideration the type of sport and training required so as to minimize risk of damage to the system.
- Athletes with a diagnosis of Wolff-Parkinson-White (WPW) pattern or syndrome should be allowed to return to play pending timely expert evaluation and treatment, as there is lack of conclusive evidence of increased risk of life-threatening arrhythmias with athletic participation.
General Concepts and Principles
...neral Concepts and Pri...
...ions...
...rations for Athletes With Arrhythm...
...thletes with symptoms of arrhythmi...
.... In athletes with symptoms of arrhythmias, diff...
...letes with symptoms of arrhythmias, eva...
...es with symptoms of or concern for arrhythmias, e...
...athletes with symptoms of or concern for arrhythm...
...In athletes with arrhythmogenic conditi...
...s with arrhythmias, clinical management strate...
...with arrhythmias, clinical management strat...
...s with arrhythmias who are not return...
...ected Ventricular Adaptation from Static...
...Potential Arrhythmic Effects of Certain Stimulan...
...rcise-induced Cardiac Remodeling (Electrical)Havin...
...rcise-induced Cardiac Remodeling (Structural)Havin...
...cision-making and Clinical Management Determ...
...hletes with arrhythmogenic conditio...
...tes with arrhythmogenic conditions, the...
...2. Model for Shared Decision-making for Athletes...
...cy Action Planning for Sudden Cardiac Arrest...
Emergency Action Planning
...training or competing at schools, recr...
...hletes training or competing at schoo...
...s competing at interscholastic levels o...
...training or competing at schools, recre...
...e 4. Key Components of Emergency Action Plans...
Sudden Cardiac Arrest in Athletes
...rdiac Arrest in Athletes...
...n Cardiac Arrest Prevention Stra...
1. In athletes, periodic preparticipa...
...ary Artery Disease and Other Structural/Electr...
...iagnostic Algorithm for the Evaluation...
...n Plan for and Immediate Treatment of Sudden...
...hletes who have collapsed and are nonrespon...
...or athletes with a known SCA-predisposing...
...thletes with a known SCA-predisposing h...
...den Cardiac Arrest Treatment and Implantab...
...etes who have experienced SCA, a comprehensi...
...tes who have experienced SCA, further evaluatio...
...who have experienced SCA, an ICD should be...
...thletes with an ICD, return to play is reasonabl...
...athletes who have experienced SCA and are underg...
...or athletes undergoing ICD implantati...
...thletes who have experienced SCA a...
...ho have experienced SCA, exercise stress te...
...hletes who have experienced SCA, an individ...
...n athletes who have experienced SCA, regular...
...with an ICD who experience an ICD shock,...
...agement of SCA in AthletesColors c...
...igure 6. Treatment of Sudden Cardi...
...Athlete-specific Advantages and Disadvantages o...
Commotio Cordis
...otio Cordis...
...is Prevention and Diagnosis...
...In athletes who have experienced SCA w...
.... For athletes participating in sports...
...es under age 13 years, the use of age-appropr...
Symptoms of Arrhythmias in Athletes
...mptoms of Arrhythmias in Athletes...
...yncope in Athletes Etiologies (Noncardia...
.... Noncardiac Causes of Loss of Cons...
...nostic and Monitoring Strategies for Syncope...
...hletes with syncope, a detailed histor...
...thletes with syncope during exertion, an E...
...In athletes with syncope during exerti...
...with syncope during exertion with high-risk fe...
...es with syncope, tests should be interpreted in th...
...In athletes with unexplained syncope o...
.... In athletes with a high suspicion of arr...
...hletes with syncope with high-risk...
...with syncope, tilt table testing is not recomme...
...n athletes with a history suggestive of non...
...isk Features for Cardiac Syncope...
...valuation of Syncope During ExerciseColors...
...atures of Ambulatory Monitors, Incl...
...of Neurally Mediated or Orthostatic Sync...
...with neurally mediated or orthostatic sy...
...ith neurally mediated or orthostatic syncope, com...
...lpitations in Ath...
...hletes with palpitations, a history, physical ex...
...thletes with palpitations associat...
...For athletes in a team setting, supplying at...
...athletes with palpitations, a personal...
Ventricular Arrhythmias
...ntricular Arrhyth...
...Ventricular Arrhythmias in Athletes...
.... In athletes with symptoms suspic...
...tes with symptoms suspicious for suspe...
...In athletes with ventricular arrhythmia...
...thletes with 2 or more asymptomatic typical PVCs,...
...thletes with 1 asymptomatic typical...
...with PVCs of a single outflow tract...
...letes with higher-risk ventricular arrh...
...In adult athletes with ventricular arrhythmi...
...athletes with ventricular arrhythmi...
...uation of Athletes With Ventricular Arrh...
...le 6. Risk Features From History and Te...
Treatment of Ventricular Arrhythmia...
...of Benign Ventricular Arrhythmias in...
...of performance-enhancing or illicit drugs, (1, C-...
...loss, (1, C-EO)3594573...
...atment of obstructive sleep apnea, (1,...
...king cessation, (1, C-EO)3594573...
...ol avoidance, (1, C-EO)359...
...e avoidance, (1, B-R)3594...
...pertension management, (1, C-EO)35...
...eassurance (1, C-EO)359457...
...e asymptomatic athlete with benign ventricular ar...
...symptomatic athlete with a high burden...
...es with symptomatic benign ventricular ar...
...letes with symptomatic benign ventricular arrh...
...In athletes with symptomatic benign ven...
...In athletes with benign ventricular arrhy...
...gure 10. Treatment of Athletes with Benign V...
...Complex Ventricular Arrhythmias in the At...
...ex Ventricular Arrhythmi...
...hlete with complex ventricular arrhythmias, mana...
...who have survived sustained ventricu...
...athletes with monomorphic ventricular arrhythmias...
...with VF triggered by monomorphic PVCs,...
...In athletes with complex ventricular arr...
.... In athletes with suspected PVC-i...
...In athletes with suspected PVC-indu...
...In athletes with ventricular arrhy...
...tes with ventricular arrhythmias and nonfamili...
...tment of Athletes With Complex Ven...
Inherited Arrhythmias and Cardiomyopathies
...ited Arrhythmias and Cardiomyopathies...
...hletes with Inherited Arrhythmia Syndrome...
...letes with inherited arrhythmia syndrom...
.... In athletes with a positive genetic test for IAS...
...s with LQTS or CPVT in whom beta blo...
...In athletes with IAS who have received a...
...es with IAS, ICD implantation for the sole...
...thletes With Long QT Sy...
...letes with LQTS under expert assessment and...
...with LQTS, review and/or cessation of...
...hletes with asymptomatic LQTS and a...
...ith asymptomatic LQTS and a corrected...
...es with LQTS with symptoms and/or a...
...etes with LQTS on beta blocker therapy, n...
...For athletes with LQTS and severe bradycardia,...
...athletes with LQTS (including type 1), partici...
...hletes with LQTS who are unable to tolerate bet...
...holaminergic Polymorphic Ventricul...
...Catecholaminergic Polymorphic Ventricular Tac...
...athletes with asymptomatic CPVT and a negati...
...94573
...etes with previously symptomatic CPVT while not o...
.... In athletes with previously sympt...
...tes with ongoing symptomatic CPVT despite...
...da Syndrome...
...hletes With Brugada Sy...
...with Brugada syndrome, avoidance...
...tment of fever (1, C-LD)3594573
...of hyperthermia (1, C-EO)3594573...
...t QT Syndrom...
...With Short QT Syndrome...
...hletes with SQTS, patient education about the i...
...n athletes with symptomatic SQTS and/or a...
...re 12. Management and Treatment of Inherited Arrhy...
...letes With Inherited Cardiomyop...
...t and Management of Athletes With Inherited Card...
...tes with inherited cardiomyopathies, e...
...letes with inherited cardiomyopathies, gen...
...with inherited cardiomyopathies con...
4. In athletes with inherited cardio...
...t and Management for Athletes With Hypertrophic ...
...Management Specific to Athletes With Hypertrophi...
1. In athletes with genotype-positive pheno...
2. In young athletes with HCM who return to play,...
...n athletes with phenotype-positive H...
4. In athletes with symptomatic obstructive HC...
...nagement Specific to Athletes With Arrhythmogen...
...with genotype-positive phenotype-negative...
...athletes with genotype-positive but phenotype-n...
...with phenotype-positive ACM, sports pa...
...es with phenotype-positive ACM and a lower-...
...thletes with phenotype-positive ACM and hi...
...etes with nonfamilial and/or genotype-neg...
...hletes with DCM who are asymptomatic with left...
...ith DCM who are asymptomatic with LVEF...
...tion of Vigorous (>6 METs) Endurance Exer...
...13. Recommendations for Athletes With Inhe...
...ng From Athlete to Family: Implications o...
1. In athletes with suspected genetic...
...es with suspected genetic heart disease ba...
...hletes with genetic heart disease who hav...
...e of genetic testing or when the athlete...
...ith a genetic variant but without phenotypic exp...
.... Athletes with a genetic variant f...
...ure 14. Flow Chart Demonstrating Appr...
Atrial Fibrillation
...al Fibrillation...
...l Fibrillation Evaluation in...
...hletes with symptoms or personal ECG (portable wea...
...In athletes with AF, a detailed history...
3. In athletes with AF, initial evalua...
4. In athletes with AF, rhythm monitoring ca...
...g and young adult athletes with AF...
...ng and young adult athletes with AF and cl...
...young adult athletes with AF, genetic testi...
...and young adult athletes with AF, w...
...with AF, recommendations regarding intensive...
...with AF, it is reasonable for patient couns...
...letes with AF should be managed in a cen...
Figure 15. Evaluation of Athletes S...
Treatment of AF in Ath...
...or Modification in Athletes With AF
...thletes with AF, risk factor management, in...
.... In athletes with AF who engage in l...
...ntion of Thromboembolism in Athlet...
...or athletes with nonvalvular AF, stroke ri...
...r athletes with nonvalvular AF with an estimate...
...ith AF on anticoagulation who are participatin...
...tes with AF, left atrial appendage occlusion (LAA...
...athletes meeting anticoagulation crite...
...ythm Control in Athletes With AF...
...lity of life (1, A)35945...
...d exercise performance (1, B-NR)3594573
...es with symptomatic AF, catheter ablation is reco...
.... In athletes undergoing catheter ablation for...
...n athletes with AF and rapid ventr...
...letes with symptomatic paroxysmal AF unde...
...with infrequent, symptomatic paroxysmal AF, ant...
...young adult athletes with AF, an EP stu...
...etes with AF, antiarrhythmic drug therapy...
...athletes with AF, catheter ablation to...
Figure 16. Evaluation and Management of Athl...