‘Tactical Athletes’ Require Different Cardiovascular Disease Care From Competitive Athletes

 Emergency responders, military service members, and firefighters face dangers every day, yet disasters, combat, and flames are not their greatest risk.

The leading cause of death on the job for these “tactical athletes” is actually cardiovascular disease. Roughly 4 million Americans are considered tactical athletes, meaning their everyday jobs require physically exerting, highly stressful work in extreme, uncertain, life-threatening conditions.

Clinical guidance for these distinctive athletes has lagged well behind that for competitive athletes, but a new scientific statement from the American College of Cardiology and the American Heart Association hopes to close that gap.

Bradley Petek, MD

“There are unique considerations one must account for when caring for tactical athletes,” said Bradley Petek, MD, a cardiologist at OHSU in Portland, Oregon, and co-author of the scientific statement. “Hopefully, these guidelines provide a framework for clinicians who care for tactical athletes to help provide the best care for this patient population.” 

Clinical Considerations

Key recommendations from the new statement include:

• An individualized approach to evaluation and risk assessment that considers specific occupational requirements and demands. The writing group designed a new evidence-based tactical clinical management framework to guide clinicians in risk assessment, medical evaluation, diagnosis, and treatment.
• Preparticipation screening for all tactical athletes, including a physical examination and medical history. Athletes younger than 40 years who expect to undergo significant cardiovascular stress, or who hold mission-critical roles, should get an ECG.
• Fitness assessments for duty should include potential risks to team members, public safety, and mission objectives.
• Consider the cardiovascular implications of certain conditions and plan ongoing monitoring accordingly.
• Assess the operational and environmental factors that may contribute to cardiovascular risk, including heat, altitude, dehydration, diving, and collision risk. Classify tactical tasks based on cardiovascular strain.
• Account for the availability of emergency medical care, including automated external defibrillators (AEDs). Encourage organizations to create emergency action plans and maintain rapid AED access.
• Recommend lifestyle modifications for conditions such as hypertension, but consider pharmacologic interventions earlier due to challenges of implementing lifestyle changes in austere environments.

“One of the greatest challenges with tactical athletes is that you can’t anticipate every possible condition or situation,” said Jeffrey Hsu, MD, PhD, a cardiologist at UCLA Health. “These clinical care considerations provide helpful guidelines and a good foundation to understand how to approach the complex decisions that can be involved with making evaluations and decisions with this population.” 

Differences for Competitive Athletes

There is some overlap in guidance, and clinical guidance for competitive athletes has evolved in recent years.

Many competitive athletes used to be prohibited from sports if they had cardiovascular issues, but recent research suggests athletes may be able to safely compete after discussing the risks with their clinicians and participating in a shared decision-making model about competition. A shared decision-making model may include physicians, athletes, family members, coaches, and teammates.

“Our main concern with athletes is the risk of sudden cardiac arrest and death with high intensity activity, whether that’s in competition or in training, so clinicians need to be familiar with these risks while balancing them with an acute understanding of the role that sport, exercise, and training plays in athletes’ lives,” said Hsu. “Whether you’re asking athletes to pause sport temporarily or permanently, it’s not a trivial recommendation.” 

Last year, the American Heart Association and the American College of Cardiology published a scientific statement updating clinical considerations for competitive athletes with cardiovascular issues. Studies in the last decade suggest the risks associated with competitive sports are not as high as once thought for conditions including congenital heart disease and arrhythmias. The statement stressed the need for shared decision-making and offered new recommendations for how to treat a number of cardiovascular conditions.

“We have moved away from a more paternalistic model of the physician completely dictating whether or not an athlete can compete in sports,” Petek said.

“It is essential to take a thoughtful and thorough approach to understanding an athlete’s underlying cardiovascular disease, the possible cardiovascular risk and prognosis of that cardiovascular disease, any potential risks for high-intensity or prolonged exercise, and an athlete’s individual wishes and patient values,” he said.

Petek added that sports cardiologists need to account for factors such as high volumes or intensities of exercise; competing or training in remote areas without easy access to healthcare facilities; and environmental extremes including temperature, altitude, and dehydration.

“Ensuring there is a well-designed, well-rehearsed emergency action plan for cardiac emergencies is one of the most important considerations for competitive athletes,” said Hsu.

Increased Risk and Consequences

While guidance for competitive athletes has shifted toward a model of shared decision-making, that approach is not recommended for tactical athletes, according to the statement. Instead, clinicians need to consider mission-specific factors.

Elizabeth Dineen, DO

“A cardiovascular event for a firefighter, police officer, or military service member can have implications far beyond the individual, including the success of the mission and lives of others,” Elizabeth Dineen, DO, chair of the writing group, said in a statement.

For example, if a firefighter collapses due to a sudden cardiac arrest while responding to a fire, that affects rescue efforts, potentially endangers others, and harms firefighting priorities. And fires, like military operations and police responses, often take place far from where an AED might be available.

“This shift in risk tolerance necessitates a distinct clinical framework that adapts classical shared decision-making to the operational realities of tactical service,” the authors wrote in the statement.

Age also plays a factor. Tactical athletes skew older than competitive athletes, with many serving into their forties, fifties, and beyond.

“You start to see a higher prevalence of conditions that increase with age, like coronary artery disease, which has to be factored into medical evaluations,” Hsu said.

While emergency action plans are critical for both populations, tactical athletes may be required to serve in locations with limited access to emergency care.

“Tactical athletes may be required to be in remote locations with limited access to outside communication, medications, and other resources which should be a consideration among individuals with cardiovascular disease,” Petek said.

Dineen reported no disclosures. Petek’s Sports Cardiology Program has received compensation for preparticipation cardiovascular screening for the NHL Scouting Combine, University of Portland, and Portland State University. In addition, his Sports Cardiology Program has received funding from the Joel Cornette Foundation for the Outcomes Registry for Cardiac Conditions in Athletes study.

https://www.medscape.com/viewarticle/tactical-athletes-require-different-cardiovascular-disease-2026a1000zue