Cardiac pauses in competitive athletes: a systematic review examining the basis of current practice recommendations

Abstract

While the evidence is not incontrovertible, the 3 s pause threshold does not adequately discriminate between potentially asymptomatic and symptomatic competitive athletes, and alone should not be used to exclude potential competitors.

Management of asymptomatic arrhythmias: a European Heart Rhythm Association (EHRA) consensus document, endorsed by the Heart Failure Association (HFA), Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin America Heart Rhythm Society (LAHRS)

“…Recently, a systematic review on cardiac pauses in competitive athletes was performed. 261 The study population comprised 194 individuals with cardiac pauses of 1.35-3.0 s. When specific records for pause durations were provided, 106 athletes had pauses < _3 s, of whom 92 were asymptomatic and 14 had pauses >3 s, of whom 9 were asymptomatic. Few subjects were deemed to require medical intervention at the time of diagnosis, and there were no deaths during 7.5 ± 5.1 years of follow-up.…”

“…Asymptomatic bradycardia is common in athletes, and the accepted 3 s pause threshold neither warrants exercise restriction or early therapeutic intervention. 261 Pauses in AF patients between 3 and 5 s are frequently seen and may be a normal occurrence. Treatment is not required except in case of symptoms.…”

Diagnosis, pathophysiology, and management of exercise-induced arrhythmias

“…Overall, sinus bradycardia at rest (with heart rate between 30-60 bpm) is found in 50-80% of athletes 127,128 and might occasionally be associated with long (>3 s) sinus pauses. 129 Although sinus bradycardia is an indisputable consequence of exercise, its causes still remain unresolved. A reduction in heart rate could potentially result from changes in the autonomic tone (that is, an increase in the parasympathetic tone or a decreased sympathetic tone) or a reduction in the intrinsic heart rate.…”

“…Only a minority of patients, particularly those with exaggerated sinus bradycardia or long pauses, will present with symptoms, generally in the form of fatigue, dizziness, or even syncope. 129,136 [H2] Therapeutic approach Most asymptomatic patients with exercise-induced bradyarrhythmias do not require any specific therapy; only those with extreme forms (for example, bradycardia <30 bpm or PR intervals >300 ms) will require additional assessment. 137 Abandoning or reducing the intensity or duration of physical activity might improve symptoms in those athletes with exercise-induced symptomatic bradycardia or atrioventricualr blocks.…”

Management of mature athletes with cardiovascular conditions

“…Endurance athletes also demonstrate a higher prevalence of type 1 second-degree AV block,30 31 and periods of low atrial or junctional escape rhythms, at rates of 40–60 bpm, are also normal phenomena. Occasionally, marked sinus bradycardia (<40 bpm) at rest or sinus pauses >3 s can be found in asymptomatic, well-trained endurance athletes 32. Such findings are usually benign, more evident at rest, particularly during sleep and do not require intervention in asymptomatic individuals.…”