New US Guidelines Okay More Sports for Athletes With Long QT, Other CV Disorders

November 06, 2015

DALLAS, TX and WASHINGTON, DC — Ten years after the publication of recommendations stemming from the 36th Bethesda Conference, the American Heart Association (AHA) and American College of Cardiology (ACC) have updated the guidelines and recommendations establishing eligibility and disqualification criteria for competitive athletes with cardiovascular disease[1].

Consisting of documents written by 15 task forces and more than 2 years in making, the AHA/ACC scientific statement covers everything from preparticipation screening for cardiovascular disease in competitive athletes to eligibility and disqualification recommendations for athletes with hypertrophic cardiomyopathy, congenital heart disease, valvular heart disease, aortic disease, hypertension, coronary disease, arrhythmias and conduction defects, and channelopathies, among others.

There are also statements from the task force on drugs/performance-enhancing substances and the establishment of emergency action plans involving cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). In the final document, the task force also addresses some of the legal aspects of medical eligibility and disqualification criteria.

The new guidelines, which are chaired by Dr Barry Maron (Minneapolis Heart Institute, MN), Dr Douglas Zipes (Indiana University, Indianapolis), and Dr Richard Kovacs (Indiana University), are published November 2, 2015 in Circulation.

"The present recommendations, formulated with respect to allowable levels of sports activity, can be regarded as generally conservative," they state in their introduction to the task-force reports. They acknowledge that recommendations from the consensus panels might lead to some athletes being unnecessarily excluded from competition, which is unfortunate, but note the increased risk of sudden death from sports is a "controllable variable."

Options for Athletes with LQTS and ICD

Despite the conservative nature of the recommendations, the experts, for the first time, have relaxed eligibility criteria for certain types of competitive athletes with cardiovascular conditions, such as those with long-QT syndrome (LQTS).

"The new guidelines really endorse more of a shared decision-making model, where doctors and patients are encouraged to engage in a discussion about risks and benefits and then to make individualized decisions," Dr Aaron Baggish (Massachusetts General Hospital, Boston, MA), coauthor of several of the new AHA/ACC scientific statements, told heartwire from Medscape. "I think that's appropriate now that we have data showing that patients with long-QT syndrome can participate with a fair degree of safety."

Since 2005, individuals with LQTS were excluded from all competitive sports. In the new guidelines, however, the experts say "it is reasonable" for asymptomatic LQTS individuals to participate in all competitive sports as long as they take certain precautionary measures, such as avoiding QT-prolonging drugs and acquiring a personal AED as part of their personal sports gear, among other measures. In addition, the school or team officials must have an appropriate action plan in place for the student.

The LQTS recommendation, which also holds for those with catecholaminergic polymorphic ventricular tachycardia (CPVT), Brugada syndrome, early repolarization syndrome, idiopathic ventricular fibrillation, or short-QT syndrome, is a class IIa recommendation (level of evidence C).

For patients with implantable devices, such as those with an ICD, the AHA/ACC experts also allow for participation in competitive sports based on new evidence. Like the other recommendations, the physician and patient should engage in a discussion about the sport-specific risks, but they do say participating in 1A sports (bowling, cricket, curling, golf, riflery, or yoga) is reasonable if the athlete is free from ventricular flutter (VF) or ventricular fibrillation (VT) requiring a shock for at least 3 months (class IIa, level of evidence C).

For other sports with higher static and dynamic components, which increase the demand for blood flow and lead to higher heart rates and greater contraction of the left ventricle, these "may be considered" for an athlete with an ICD if they are free from VF or VT requiring a shock for at least 3 months (class IIb, level of evidence C).

To heartwire , Baggish said the data have shown that athletes with ICDs can participate in sports without an increase in sudden cardiac death, although the caveat is that sports participation does result in a higher ICD discharge rate. "If staying is alive is what matters, then a lot of us have found that ICD patients do better than expected," he said.

For patients with hypertrophic cardiomyopathy, the new recommendations are similar to previous iterations, with the AHA/ACC experts still recommending these individuals avoid intense competitive sports. For those with an "unequivocal clinical expression and diagnosis of hypertrophic cardiomyopathy," an exception can be made for low-intensity sports, such as bowling or curling. ICDs should not be placed in patients with hypertrophic cardiomyopathy for the sole or primary purpose of playing high-intensity sports, they add.

Regarding preparticipation screening for athletes, the experts say large-scale cardiovascular screening with a 12-lead ECG in individuals aged 12 to 25 years old (junior high school, high school, and college-aged athletes) is not recommended, nor is it recommended on a national basis in the US. The use of mandatory mass screening for genetic/congenital and other cardiovascular abnormalities in healthy 12- to 25-year-olds is not recommended, either. Instead, the experts recommend the AHA 14-point screening guidelines—those that involve a comprehensive history and physical examination—to detect or raise awareness about any potential cardiovascular abnormalities.

The three cochairs—Maron, Zipes, and Kovacs—report no relevant financial relationships, nor does Baggish.

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