Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 9: Arrhythmias and Conduction Defects

Abstract

A broad range of variations in heart rates and rhythms, specific cardiac arrhythmias, and atrioventricular (AV) and intraventricular conduction disturbances are observed in athletes. Although most are common among nonathletes as well, the special circumstances and pressures related to athletic performance demand a high level of attention. The distinction between normal variants, often exaggerated by the specific physiology of the conditioned athlete, and arrhythmias that may be symptomatic or life-threatening may be significant challenges. Bradycardia Sinus BradycardiaSinus bradycardia, defined as a sinus rate <60 beats per minute (bpm), is common in the athlete.1 Generally, it is attributed to enhanced vagal tone caused by conditioning and is thus physiological. Occasionally, heart rates can be as slow as 30 to 40 bpm at rest in the highly conditioned athlete and decrease to <30 bpm during sleep. Some athletes with marked sinus bradycardia will exhibit periods of low atrial or junctional escape rhythms with rates of 40 to 60 bpm. This is a normal phenomenon, and these will become suppressed with exercise-induced increases in the sinus rate.Evaluation of the athlete with sinus bradycardia includes a careful history to determine whether the athlete has symptoms related to the bradycardia. In addition, physical examination and an ECG are warranted, with selective use of additional tests such as an echocardiogram and exercise stress test if underlying structural heart disease is suggested. Stress testing can also be used to verify a normal rate response to exercise, if judged to be necessary. The same approach applies to the sinus arrhythmia commonly observed in the athlete. Generally, asymptomatic sinus pauses or sinus arrest (<3 seconds) are not considered clinically significant unless accompanied by symptoms. Pauses of longer duration may fall within the spectrum of physiological responses to athletic conditioning; however, when accompanied by symptoms, sinus bradycardia, The American Heart Association and the American College of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.The Preamble and other Task Force reports for these proceedings are available online at http://circ.ahajournals.org (Circulation. 2015;132:e256-e261; e262-e266; e267-e272; e273-e280; e281-e291; e292-e297; e298-e302; e303-e309; e310-e314; e326-e329; e330-e333; e334-e338; e339-e342; e343-e345; and e346-e349).This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 24, 2015, and the American Heart Association Executive Committee on July 22, 2015, and by the American College of Cardiology Board of Trustees and Ex...

Ventricular Arrhythmias in Young Competitive Athletes: Prevalence, Determinants, and Underlying Substrate

“…According to a prespecified study protocol, we reserved CMR in case of frequent, complex, or exercise‐induced arrhythmias, which are a recognized subgroup with high risk of underlying cardiovascular disease 5, 15, 16, 17. In 3 of these athletes, postcontrast CMR sequences allowed identification of LV LGE with a subepicardial/midmyocardial (ie, nonischemic) pattern, which was not associated with wall motion abnormalities detectable by either echocardiography or cine‐CMR because of its segmental distribution confined to the outer layer of LV musculature.…”

“…According to previous studies indicating that cardiovascular diseases are more commonly observed in athletes with frequent (>500 PVBs/24 hours), exercise‐induced, or complex VAs, further imaging study by CMR was reserved to athletes fulfilling these arrhythmic criteria, in addition to those with abnormal echocardiographic findings 5, 15, 16, 17. Echocardiography and CMR were also performed in a control group of athletes with no or rare (≤10) isolated PVBs matched with a 1:1 ratio for sex, age class, and type of sport, who volunteered to participate.…”

Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators

“…These data can guide more informed individualized physician and patient decision making for sports participation for athletes with ICDs and continue to support the recent change in eligibility recommendations. 4 …”

Syncope in the young athlete: Assessment of prognosis in subjects with hypertrophic cardiomyopathy

“…31,42 This recommendation is being reassessed by the AHA/ACC on the basis of recent data. 50 Furthermore, athletes with ICDs, if they have a history of ventricular flutter or ventricular fibrillation, may only engage in class IA sports after a period of three months without episodes requiring device therapy. 50 When appropriate or inappropriate ICD interventions occur, a six-week period refraining from sports should be considered to assess the effect of changes in ICD programming.…”

“…39 According to the AHA/ACC, in athletes with ICDs, participation in class IA sports is reasonable after a period of three months without episodes of ventricular flutter or ventricular fibrillation requiring device therapy (no information is given about the presence of underlying structural heart disease). 50 In 2003, in a group of 132 ICD recipients with HCM, Begley et al observed that 88% of appropriate ICD discharges occurred during sedentary or mild to moderate activity. 51 In eight patients (12%) shocks were delivered during strenuous competitive sports (50% of these during basketball or soccer games) and all were successful.…”