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
...ral Concepts and Principles
.... Definitions...
...ical Considerations for Athletes With Arrhythmia...
...thletes with symptoms of arrhythmias, clin...
...tes with symptoms of arrhythmias,...
...with symptoms of arrhythmias, evaluation sho...
...hletes with symptoms of or concern...
...tes with symptoms of or concern for arrhythmias,...
...hletes with arrhythmogenic conditions retur...
...letes with arrhythmias, clinical management...
...s with arrhythmias, clinical management st...
...In athletes with arrhythmias who are not retu...
...gure 1. Expected Ventricular Adapta...
...ble 2. Potential Arrhythmic Effects of Certain...
...ercise-induced Cardiac Remodeling (Elec...
...xercise-induced Cardiac Remodeling (St...
...Decision-making and Clinical Manageme...
...thletes with arrhythmogenic conditions, determi...
...s with arrhythmogenic conditions,...
...gure 2. Model for Shared Decision-making for A...
...on Planning for Sudden Cardiac Arrest...
...y Action Planning...
...athletes training or competing at...
...etes training or competing at scho...
...etes competing at interscholastic levels or in ot...
...athletes training or competing at scho...
...mponents of Emergency Action Plans...
Sudden Cardiac Arrest in Athletes
...ardiac Arrest in Athletes...
...den Cardiac Arrest Prevention Strategies...
...periodic preparticipation evaluations includin...
...ure 3. Coronary Artery Disease and Ot...
.... Diagnostic Algorithm for the Evaluation of SCA...
...ergency Action Plan for and Immediate...
...In athletes who have collapsed an...
...r athletes with a known SCA-predisposing...
...n athletes with a known SCA-predisposing h...
...ac Arrest Treatment and Implantable Cardioverter-D...
...letes who have experienced SCA, a comprehensive e...
...tes who have experienced SCA, further e...
...s who have experienced SCA, an ICD should b...
.... In athletes with an ICD, return to...
...etes who have experienced SCA and are...
...undergoing ICD implantation who will be re...
...who have experienced SCA and have an ICD, ICD d...
...athletes who have experienced SCA, exercise...
...thletes who have experienced SCA, an individu...
...In athletes who have experienced SCA, regu...
...with an ICD who experience an ICD shock, an e...
...Management of SCA in AthletesColors correspond to...
...eatment of Sudden Cardiac Arrest Ba...
...Athlete-specific Advantages and Disadvantages of...
Commotio Cordis
...mmotio Cordis
Commotio Cordis Prevention and Diagnosi...
...athletes who have experienced SCA with...
...For athletes participating in sports fo...
...under age 13 years, the use of age-approp...
Symptoms of Arrhythmias in Athletes
...mptoms of Arrhythmias in Athle...
...n Athletes Etiologies (Noncardiac Differential...
...ble 5. Noncardiac Causes of Loss of Consc...
...c and Monitoring Strategies for Sync...
...with syncope, a detailed history and physical e...
...letes with syncope during exertion,...
...etes with syncope during exertion with high-...
4. In athletes with syncope during exer...
...ith syncope, tests should be interpreted...
.... In athletes with unexplained syncope or when...
...tes with a high suspicion of arrhythmic...
...letes with syncope with high-risk features and ne...
...letes with syncope, tilt table testing is not rec...
...tes with a history suggestive of noncardiac syncop...
...gh-risk Features for Cardiac Syncope...
...8. Evaluation of Syncope During ExerciseColo...
...e 7. Features of Ambulatory Monitors, Including...
...eatment of Neurally Mediated or Ort...
...tes with neurally mediated or orthostatic...
...etes with neurally mediated or orthostatic s...
...ations in Athlet...
.... In athletes with palpitations, a hi...
...hletes with palpitations associated with ex...
...thletes in a team setting, supplying athlet...
...thletes with palpitations, a personal (portab...
Ventricular Arrhythmias
...cular Arrhythmias...
...luation of Ventricular Arrhythmias in...
...tes with symptoms suspicious for ventric...
...s with symptoms suspicious for suspected ventric...
...tes with ventricular arrhythmias, taking a history...
...letes with 2 or more asymptomatic typical PVCs...
...athletes with 1 asymptomatic typical PVC (single o...
...with PVCs of a single outflow tract or fascicula...
...etes with higher-risk ventricular arrhythmias and/...
...In adult athletes with ventricular...
...with ventricular arrhythmias with higher-risk...
...aluation of Athletes With Ventricular Arrhythmias...
...6. Risk Features From History and...
...ment of Ventricular Arrhythmias in the At...
...eatment of Benign Ventricular Arrhythmias in...
...oidance of performance-enhancing or illicit...
...ght loss, (1, C-EO)3594573...
treatment of obstructive sleep apnea, (1,...
...cessation, (1, C-EO)3594573...
...ol avoidance, (1, C-EO)3594573...
...oidance, (1, B-R)3594573...
...sion management, (1, C-EO)3594573...
...s reassurance (1, C-EO)3594573...
...the asymptomatic athlete with benign ventric...
...ptomatic athlete with a high burden of benign PV...
4. In athletes with symptomatic benign vent...
...thletes with symptomatic benign ventricular ar...
...n athletes with symptomatic benign ventricular...
...letes with benign ventricular arrhyt...
.... Treatment of Athletes with Benign Ventr...
...t of Complex Ventricular Arrhythmi...
...mplex Ventricular Arr...
...e athlete with complex ventricular...
...who have survived sustained ventricular...
...In athletes with monomorphic ventricular arrhy...
...athletes with VF triggered by monomorphic...
...athletes with complex ventricular arrhythm...
...es with suspected PVC-induced card...
...athletes with suspected PVC-induce...
...In athletes with ventricular arrhythmia...
...tes with ventricular arrhythmias and nonfamilial a...
...11. Treatment of Athletes With Complex Ventricu...
Inherited Arrhythmias and Cardiomyopathies
...ythmias and Cardiomyopathies...
...th Inherited Arrhythmia Syndromes...
...n athletes with inherited arrhythmia syndromes (...
...In athletes with a positive genetic test for I...
...athletes with LQTS or CPVT in whom beta bl...
...n athletes with IAS who have receiv...
...tes with IAS, ICD implantation for the sole purpo...
...es With Long QT Syndrome...
...ith LQTS under expert assessment and...
...athletes with LQTS, review and/or cessation of med...
...thletes with asymptomatic LQTS and a norm...
...hletes with asymptomatic LQTS and a corrected QT...
.... In athletes with LQTS with symptoms and/or a...
...thletes with LQTS on beta blocker therap...
...hletes with LQTS and severe bradycardia,...
...athletes with LQTS (including type 1), par...
...hletes with LQTS who are unable to tol...
...aminergic Polymorphic Ventricular Tachycar...
...letes With Catecholaminergic Polymorph...
...thletes with asymptomatic CPVT and a...
35945...
...ith previously symptomatic CPVT while not on...
...with previously symptomatic CPVT f...
.... In athletes with ongoing symptomatic CPVT desp...
Brugada Syn...
...ith Brugada Syndrome...
...athletes with Brugada syndrome, avoidanc...
...tment of fever (1, C-LD)3594573...
...avoidance of hyperthermia (1, C...
...QT Syndrome...
...With Short QT Syndrome...
1. In athletes with SQTS, patient education a...
...ith symptomatic SQTS and/or a QTc...
.... Management and Treatment of Inherited Arrhyth...
...th Inherited Cardiomyopathies...
...nagement of Athletes With Inherited...
...In athletes with inherited cardiomyopathies, e...
...with inherited cardiomyopathies, genetic testing...
...etes with inherited cardiomyopathies con...
...In athletes with inherited cardiomy...
...tment and Management for Athletes With Hypertr...
...Management Specific to Athletes With Hypertr...
.... In athletes with genotype-positive...
...young athletes with HCM who return t...
...athletes with phenotype-positive HCM, parti...
...ith symptomatic obstructive HCM, int...
...pecific to Athletes With Arrhythmogenic and Dilat...
...thletes with genotype-positive phenotype-n...
.... In athletes with genotype-positive but p...
...n athletes with phenotype-positive...
...In athletes with phenotype-positive ACM...
...In athletes with phenotype-positive ACM a...
...athletes with nonfamilial and/or genotype-negativ...
...In athletes with DCM who are asymptom...
...s with DCM who are asymptomatic with...
...e 8. Association of Vigorous (>6 METs) Endur...
...ommendations for Athletes With Inherited Car...
...rom Athlete to Family: Implications of a Ge...
1. In athletes with suspected genetic heart disea...
...hletes with suspected genetic heart disease ba...
3. In athletes with genetic heart disea...
...ce of genetic testing or when the ath...
...tes with a genetic variant but without phenotyp...
...Athletes with a genetic variant fo...
...ure 14. Flow Chart Demonstrating Approa...
Atrial Fibrillation
...al Fibrillation...
...llation Evaluation in Athletes...
...tes with symptoms or personal ECG...
...tes with AF, a detailed history and phy...
...es with AF, initial evaluation shou...
...es with AF, rhythm monitoring can be use...
...In young and young adult athletes with...
...young adult athletes with AF and clinical susp...
...young adult athletes with AF, genetic test...
...oung and young adult athletes with AF, wit...
...es with AF, recommendations regarding intensi...
...with AF, it is reasonable for patient counselin...
...hletes with AF should be managed in a cent...
...uation of Athletes Suspected of Having...
...atment of AF in Athletes...
...Factor Modification in Athletes With AF...
...thletes with AF, risk factor managem...
...athletes with AF who engage in long-t...
...revention of Thromboembolism in Athl...
...For athletes with nonvalvular AF, stroke risk asse...
2. For athletes with nonvalvular AF with a...
...s with AF on anticoagulation who are partic...
...In athletes with AF, left atrial append...
...thletes meeting anticoagulation crit...
...and Rhythm Control in Athlete...
...uality of life (1, A)3594573
...ercise performance (1, B-NR)3594573...
...In athletes with symptomatic AF, catheter a...
...hletes undergoing catheter ablatio...
...with AF and rapid ventricular rate, control...
...hletes with symptomatic paroxysmal...
...athletes with infrequent, symptomatic paroxys...
...nd young adult athletes with AF, an EP study is re...
...thletes with AF, antiarrhythmic drug therapy with...
...In athletes with AF, catheter ablatio...
...aluation and Management of Athletes Suspec...