Physicians should use shared clinical decision-making to help manage a return to play for athletes with arrhythmias, according to a new consensus statement from the Heart Rhythm Society.
The statement was released at the society's annual meeting in Boston and published simultaneously in the journal Heart Rhythm.
"Traditionally, the guideline going back 20 years reflected a paternalistic approach that if you have a certain condition, we shouldn't risk it, you shouldn't play," Eugene Chung, MD, MPH, MSc, director of the sports electrophysiology clinic at Massachusetts General Hospital, Boston, and vice-chair of the consensus statement writing committee, said in an interview. "But as time has passed, the experience that we gained, as research and data have been accumulated, we realize those approaches have been too restrictive.
"So, with increasing data behind it and experience taking care of these patients, more and more we can recommend a path to returning to sport and play for patients, even with conditions we would've normally restricted before, such as hypertrophic cardiomyopathy."
The statement builds on past recommendations from the American Heart Association and the American College of Cardiology and the European Society of Cardiology, along with other previously published recommendations.
The statement emphasizes that physicians should consider how various treatment options, such as medication, ablation, or device implantation, might affect a person's athletic performance when making decisions about how to manage their condition. The statement noted that data have not confirmed an increased risk of life-threatening arrhythmias from continued sports participation for patients who are closely managed.
Notable Updates
Three specific updates in the consensus statement are most noteworthy, Chung said.
- In patients with arrhythmia who are taking medication for the symptoms, physicians should perform a stress test to document that the arrhythmia has been suppressed before allowing them to return to play. Stress testing should closely resemble the activity they're doing, Chung added.
- The recommendation for first-line atrial fibrillation ablation in athletes has been upgraded to Class 1 from Class 2A in previous guidelines. "We felt that there are enough data — albeit mostly in the general population — paired with observation data, that athletes do just as well as the general population, and that promoting exercise, especially moderate level exercise, helps reduce atrial fibrillation," he said.
- Patients with the Wolff-Parkinson-White pattern on electrocardiography require a close workup and monitoring. "Data over the past 10 years have shown that risk is not as low as we once thought, and we emphasize that patients with this type of pattern on ECG should see an expert," Chung explained.
Shared decision-making is heavily emphasized in the guidelines. Chung gave as an example people who participate in sports that require strenuous arm motion, such as rowing or weight lifting, who need a defibrillator or pacemaker. There are now subcutaneous options more amenable to those activities, Chung pointed out. "But to go down these decision trees, we want to certainly involve the patient and their family where appropriate and make sure we're all on the same page," he said.
Return to Play
This document updates and builds on the evidence supporting return to play, said T. Jared Bunch, MD, a professor at University of Utah School of Medicine, Salt Lake City, who specializes in arrhythmias in athletes.
"It's the right time and the right place," he said. "It's really needed, and some of it is in the context of the history of how we've restricted return to play."
The shared decision-making component is important, Bunch said, because "it brings in the patient, their interests and desires."
"Everybody has inherent thresholds of risk they want to take," he said. "In a young child, they're thinking in the immediate now and may not have a long-term perspective, so parents are important."
The next step is to evaluate the recommendations laid out in the statement, Bunch added. "Now the society has the impetus and need to evaluate the impact of what we're doing," he said. "If we allow more kids to participate in return to play, we need to have the research infrastructure to make sure that it's safe, that event rates aren't changing, that it supports our recommendations because throughout the guideline some of the recommendations were not based on a lot of strong evidence. These are small populations, and these are rare events."
https://www.medscape.com/viewarticle/athletes-heart-problems-can-continue-play-2024a10009ny
