Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators

Abstract

U ntil 2015, consensus statements 1,2 advised against sports participation more vigorous than golf for patients with implantable cardioverter-defibrillators (ICDs) because of the postulated risks of death caused by failure to defibrillate, injury resulting from arrhythmia-related syncope or shock, or device damage. The multinational, prospective, observational ICD Sports Safety Registry quantified risks associated with sports participation for athletes receiving ICDs on the basis of standard criteria. Initial results (2013 3 ) demonstrated no death, failure to defibrillate, or injury resulting from arrhythmia or shock during sports. On the basis of these data, the 2015 eligibility and disqualification recommendations for competitive athletes with cardiovascular disease 4 now state that competitive sports may be considered for athletes with ICDs. This report describes 4-year follow-up of the completed registry. Methods are as reported previously.3 The Yale University Human Investigation Committee approved the study. All participants gave written informed consent.Among 440 participants, 393 in organized sports and 47 in high-risk sports, the most common diagnoses were long-QT syndrome (n=87, 20%), hypertrophic cardiomyopathy (n=75, 17%), and arrhythmogenic right ventricular cardiomyopathy (n=55, 13%). Of 201 subjects with a preimplantation history of ventricular fibrillation (VF) or tachycardia (VT), 61 (30%) had VT/VF during sports. At enrollment, median time since implantation was 26 months (interquartile range, 11-59 months), with 126 subjects (29%) enrolled within 1 year of implantation. The most common organized sports were running, basketball, and soccer; the most common dangerous sport was skiing. Seventy-seven subjects (18%) engaged in varsity/junior varsity/ traveling team competition, (highly competitive subgroup). Seventy-two postcollege athletes (16%) participated at a national/international level.Median follow-up was 44 months (interquartile range, 30-48 months), totaling 1446 person-years. Thirty-seven participants did not complete the study: 20 were lost to follow-up (all confirmed alive), 5 withdrew, 6 developed worsening cardiac/ medical conditions, 4 had the ICD removed, and 2 died (neither death was sports related, as reported previously 3 ). There were no tachyarrhythmic deaths or externally resuscitated tachyarrhythmias during or after sports participation or injury resulting from arrhythmia-related syncope or shock during sports. The 95% confidence interval for the occurrence of adverse event based on 376 participants followed up at least 2 years was 0% to 0.9% and based on 167 participants followed up at least 4 years was 0% to 2.2%.The numbers and rhythms of shocks received for the overall group and the highly competitive subgroup are shown in the Table. Forty-six (10%) received appropriate shocks (for VT/VF) during competition or practice, a rate of 3 per 100 person-years (identical to the initial report 3 ). More participants received shocks during competition/ practice or physical a...

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

“…38,39 Based on this fact, the ICD Sports Safety Registry, an observational prospective registry, was established to follow individuals with an ICD who have made the decision to participate in sports. 53 There were 49 shocks in 37 participants (10% of the study population) during competition or practice, 39 shocks in 29 participants (8%) during other physical activity, and 33 shocks in 24 participants (6%) at rest. Ultimately, the ICD terminated all episodes, despite the occurrence of both inappropriate and appropriate shocks.…”

Sports and Exercise in Athletes with Hypertrophic Cardiomyopathy

“…Perhaps most telling of all, most athletes who received a shock during competition chose to continue playing after the shock. 95 A total of 13 definite and 14 possible lead malfunctions were reported, which translates into event rates comparable with those of nonathlete populations. Thus, theoretic concerns about competing with an ICD are now being questioned.…”

“…Concern for this patient group is founded on 3 main premises, namely, the device fails to recognize and treat fatal arrhythmias, it incorrectly recognizes and treats nonlethal rhythms, and defibrillation, be it appropriate or inappropriate, may subject the athlete and others in the vicinity to significant trauma. 15,95 Physicians have also voiced concern that the device and its leads are at significant risk for damage, particularly in contact sports, and that malfunction could ensue with unacceptable frequency. There is additional hypothetical concern that exercise-induced physiologic changes (ie, alterations in electrolytes, autonomic tone, myocardial oxygenation, and neurohormonal milieu) could increase the defibrillation threshold and also interfere with device function.…”

“…Among 372 patients with an ICD, including 65 with HCM, followed up for a median of 31 months, there were no deaths, resuscitated arrests, or defibrillation-related injuries despite participation in high-intensity competitive sports. 95 About 21% of this patient population received a shock from their device, and 73% of these shocks occurred during physical activity. About 13% experienced a shock appropriately and 11%, inappropriately.…”

How to Practice Sports Cardiology

“…6 This document has been criticized for being too restrictive and lacking an evidence base. 2,49,50 Preliminary data in athletes and exercising individuals with implanted defibrillators, 51 and long QT, 52 suggest that the risk of exercise and/or sports may be acceptably low in certain individuals with these conditions. Further studies are planned, but outcome data like this will provide the Bethesda (participation recommendation) writers with information they need to allow the guideline to evolve.…”