With increased public awareness of the risk for sudden death during athletic participation, as well as advances in the detection of cardiovascular diseases that may result in cardiovascular collapse during exercise, significant effort and some progress has been made in the development of criteria to determine which athletes may require disqualification from competitive sports.Reference Maron, Zipes and Kovacs 1 At the same time, a number of advances have been made in the treatments potentially available for the competitive athlete with a cardiovascular disease that potentially may allow the athlete to return to active competition.Reference Lampert and Cannom 2 , Reference Oliveira and Lawless 3
However, in contrast to evolving criteria to potentially determine which conditions disqualify athletes from active competition, there has been minimal progress in the development of criteria to determine whether and when an athlete, who has been diagnosed with or treated for a cardiovascular disease, may resume his or her sport. It is the purpose of this report to discuss which physician, in the setting of organised competitive sports, has the ultimate authority to determine whether an athlete may return to play, and - when data are available - what protocols exist to guide the cardiology consultant to advise the team physician as regards whether and when athletic participation may resume for an athlete with a cardiovascular diagnosis. For the purposes of this report, an athlete is defined as an individual who participates in an individual or team organised sport, which places a high premium on excellence and outcome, and requires systematic and intense training.Reference Maron, Zipes and Kovacs 1
Return to play in organised sports – who decides?
The decision process of athletic disqualification following diagnosis of a previously unrecognised cardiovascular condition such as long QT syndrome or hyertrophic cardiomyopathy may occur at several levels. It may be invoked by the athlete or the immediate family because of the potential risk for a catastrophic cardiovascular event, or it may be made by the team physician in consultation with the patient’s cardiologist. In certain instances the athlete may petition the school or athletic organisation to allow participation using an “athlete informed consent model”.Reference Mitten, Zipes, Maron and Bryant 4 In this setting the school or athletic organisation may allow participation or deny it for medical or legal concerns. Finally, in rare cases, the judicial system has been involved in disputes to determine whether the individual athlete should be allowed to participate in competitive sports.Reference Maron, Mitten, Quandt and Zipes 5 , 6
Conversely, the return-to-play decision is usually made under a different set of dynamics, wherein the individual player, the coach, and the team are all pushing for the player to be quickly cleared to return to active competition.Reference Kroshus, Baugh, Daneshvar, Stamm, Laursen and Austin 7 The team physician or consultants ideally predicate their return-to-play decision on the basis of the long-term health of the athlete, rather than on the outcome of competition. However, the reality is that the team physician is often in a “conflicted situation” where he/she is often employed by the team and supports team goals as well as that of the individual athlete. In fact, the role of the team physician and this type of conflict is recognised as one of the more difficult bioethical dilemmas in modern medicine.Reference Testioni, Hornik, Smith, Benjamin and McKinney 8
The role of the team physician as the final authority on return-to-play decisions is stated in absolute terms by the National Collegiate Athletic Association (NCAA) Sports Medicine Guidelines: 9
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∙ The team physician has the final responsibility to determine when a student-athlete is removed or withheld from participation.
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∙ In addition, clearance to return to play is solely the responsibility of the team physician or the physician’s designated representative.
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∙ During an NCAA championship event, the designated NCAA tournament physician has unchallengeable authority to determine whether a student-athlete has an injury or a condition that disqualifies the student-athlete from participation.
In general, in the absence of a defined team physician, most athletic organisations have a designated medical officer or director who functions in this regard. At the high-school level, this may be an unofficial title/role, often filled by the general medical staff of the high-school district or league.
It is noteworthy that the NCAA guidelines specifically discuss a large number of medical issues related to disqualification and return to play, including concussion, orthopaedic injuries, heat illness, and sickle cell anaemia. However, there is no discussion of cardiovascular conditions under the many medical issues considered, nor in the section titled “Catastrophic Incidents in Athletics”.
It is further important for the team physician or consultants to recognise that highly competitive athletes often are not compliant with medical recommendations as regards withdrawal or limitations in training until full clearance is given. In a recent nationwide survey of 479 NCAA athletic trainers, only 2% of collegiate athletes were perceived to be absolutely compliant with medical restrictions, 28% were reported usually compliant, whereas 48% of athletes were viewed sometimes complaint and 20% non-compliant.Reference Granquist, Podlog, Engel and Newland 10
Therefore, the decision regarding return to play for the athlete is ultimately the decision of the team physician or delegate. Despite the ultimate authority in this decision process, the team physician has a conflicted role, both as advocate for the health of the athlete as well as supporting the goals and success of the team. These may be difficult decisions given the inherent conflict in this process as well as lack of objective data to guide the decision process. Furthermore, even if a recommendation is made to restrict the athlete from training or further competition, highly competitive athletes, who have trained for years and identify themselves and their future primarily through their sport, often do not follow prescribed medical limitations.
Return-to-play decisions in specific cardiovascular conditions
Because of concerns regarding unrecognised traumatic brain injury, a number of return-to-play protocols have been developed for athletes who incur a concussion during athletic participation. These protocols have been widely endorsed by various medical organisations, although their benefit remains a matter of dispute.Reference Moser, Schatz and Lichtenstein 11 Following the development of return-to-play concussion protocols, a number of additional protocols have been developed both for specific orthopaedic injuries, such as anterior cruciate ligament and ankle injuries, and for sport-specific injuries such as those related to football or soccer. However, as of this time, there are no specific protocols related to return to play following treatment of various cardiovascular conditions in competitive athletes.Reference Panhuyzen-Goedkoop and Smeets 12 The following is a discussion of some of the common cardiac conditions and their treatments that occur in competitive athletes and what criteria may determine whether and when return to play is allowed.
Return to play following catheter ablation
Supraventricular tachycardia is a relatively common problem, both in the general population and in competitive athletes. Catheter ablation has been accepted as the definitive method for cure for supraventricular tachycardia, either due to an accessory atrio-ventricular connection or due to atrio-ventricular node re-entry. The methods of catheter ablation have evolved over the past 20 years and now allow for a relatively limited procedure that can be performed expeditiously on an out-patient basis.
Return to play following a catheter ablation procedure was first discussed in the 2002 European Society of Cardiology/American Society of Sports Medicine guidelines with an update in 2005.Reference Pellicia, Fagard and Bjornstad 13 In this document, competitive athletes with supraventricular tachycardia were allowed to participate in all sports 1–3 months post procedure if there were no symptoms, or within “days” if a repeat electrophysiology study was performed that confirmed the efficacy of the procedure. Of note, the updated 2005 document advised return to play after an interval of 3–6 months if a repeat electrophysiology procedure was not performed.
Similar recommendations were made for patients with ventricular pre-excitation (Wolff–Parkinson–White syndrome) with return in 1–3 months if there were no symptoms or within “days” if a repeat electrophysiology study was normal. Of note, ablation was considered “mandatory” for all athletes with Wolff–Parkinson–White syndrome. Also, no mention is made of a repeat electrocardiogram (ECG) before return to play to assess for recurrence of pre-excitation. Return to play following catheter ablation of focal right ventricular outflow tract tachycardia or left ventricular fascicular tachycardia was advised after a 2–3-month symptom-free interval and an exercise test that was negative for ventricular ectopy.
Post-ablation return-to-play recommendations were made in the 36th Bethesda Guidelines (2005) advising a 2–4-week interval post procedure for supraventricular tachycardia ablation or “days” if a repeat electrophysiology study was performed.Reference Zipes, Ackerman, Estes, Grant, Myerburg and VanHare 14 Again, no discussion of a repeat ECG before return to play was made following catheter ablation for Wolff–Parkinson–White syndrome. Despite continued progress with this therapy, the 2015 Bethesda Update did NOT discuss return-to-play considerations post-ablation.Reference Zipes, Link, Ackerman, Kovacs, Myerburg and Estes 15
Currently, most ablation procedures are performed on an out-patient basis, with small incisions in the groin the only area that require healing. Although there are no published data on this, it would appear that most competitive athletes return to full competition within one week of their procedure, provided they are symptom free and their ECG is normal.
Return to play following cardiac device implantation
Compared with catheter ablation, the use of pacemakers and implantable cardioverter-defibrillators is relatively infrequent in athletes. In general, the return-to-play decision in an individual with a pacemaker is predicated primarily on the type of associated heart disease, rather than on the mere presence of the pacemaker. The European guidelines and various websites advise return to play 4–6 weeks post pacemaker implant.Reference Heidbucchel, Panhuyzen-Goedkoop and Corrado 16 There is general consensus to avoid activities that pose risk of direct trauma to the device, and to limit above shoulder-level arm exercises to prevent potential crush of the pacemaker lead.
The 2015 Bethesda Guidelines similarly stated that the mere presence of a pacemaker does not equate to automatic disqualification. In general, athletes with no associated heart disease are cleared for participation. Further decisions regarding restrictions are based on the level of pacemaker dependence and associated cardiovascular disease. The risks of trauma are generally sport specific and defined in the Bethesda document.Reference Maron, Zipes and Kovacs 1 Finally, an exercise test is advised before return to play to assess whether the individual’s exercise capacity is adequate for the sport and whether pacemaker programming is optimal.Reference Zipes, Link, Ackerman, Kovacs, Myerburg and Estes 15
In 2008, members of the Pediatric and Adult Congenital Electrophysiology Society were surveyed regarding their practices for athletic participation following pacemaker implantation.Reference Gajewski, Reed and Pilcher 17 Of the 75 responders, 15% did not restrict athletic participation, 65% allowed participation in at least one organised athletic activity, whereas 20% prohibited activities other than level 1A.
The decision/controversy regarding return to play in the athlete with an implantable cardioverter-defibrillator implant is discussed elsewhere in this supplement. Of note, the American Heart Association and National Institutes of Health advise against driving for 1 week post implant if the device is implanted for primary prevention. If there has been a prior sustained ventricular arrhythmia, driving is “discouraged” for 6 months, whereas the European guidelines “discourage” driving for 3 months following an arrhythmia or device therapy. 18 The European guidelines advise no vigorous exercise or contact sports for 4–6 weeks post implantable cardioverter-defibrillator (ICD) implant, similar to the pacemaker guidelines.
The 2015 Bethesda Guidelines recognise the ongoing controversy regarding sports participation by athletes with ICDs. The current recommendations are, first, to allow level 1A sports 3 months post implant if the patient is asymptomatic post ICD implant. Second, a point of emphasis was that ICD indications for athletes should NOT be different from that for the general population. Finally, third, participation in sports higher than 1A may be considered after 3 months if there have been no arrhythmias – with recognition of the increased risk for in/appropriate ICD shock and risks for device-related trauma in high-impact sports.Reference Ackerman, Zipes, Kovacs and Maron 19
Return to play in the athlete with unexplained exertional syncope
The first statement of the 2015 Bethesda Guidelines regarding syncope is the need to differentiate exertional from post-exertional syncope.Reference Zipes, Link, Ackerman, Kovacs, Myerburg and Estes 15 Following this, the primary purpose of the cardiac evaluation is to diagnose or exclude the presence of structural heart disease or a primary electrical disorder that may predispose to sudden cardiac death. In summary, the following recommendations were made:
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∙ For athletes with syncope due to a cardiac diagnosis, activities are restricted as based on recommendations for the specific disease.
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∙ Athletes with neurally medicated syncope may resume all activities – once treatment(s) are demonstrated to prevent recurrences.
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∙ Athletes with syncope of unknown aetiology – with no defined structural abnormality or molecular diagnosis – should not participate in sports where loss of consciousness would be dangerous.
Of note, in the NCAA Sports Medicine Handbook, there is discussion of exertional collapse – however, the only cause discussed is exertional rhabdomyolysis.
Return to play in the athlete with an abnormal genetic test
A novel, yet potentially increasingly common scenario is presented by the return-to-play decision when an athlete has a positive genetic test in the absence of any overt expression of disease. This may occur when there is a family member with hypertrophic cardiomyopathy or Marfan syndrome, or when there is further evaluation of possible long QT syndrome or unexplained exertional syncope. This raises several ethical questions – if the screening test is positive and the athlete ignores the results, does the physician have an obligation to disclose the results to the team? If he does, is physician-patient confidentiality violated? Furthermore, if participation is prohibited, is this a Genetic Information Non-Discrimination Act violation?Reference Hudson, Holohan and Collins 20 The Genetic Information Non-Discrimination Act prohibits health insurers from using genetic information to determine eligibility or premium; second, it prohibits employers from using genetic information in making decisions regarding hiring, firing, job assignments, or any other terms of employment. These issues are only now being addressed, and this new clinical scenario is far from resolution. At minimum, a close working relationship between the athlete/family and team physician is required. Adjudication by an external expert may be advantageous in some instances.
Emergency action plans
To provide an additional level of safety during return to sports, cardiologists and sports medicine providers have advocated for the implementation of emergency action plans at schools and sporting venues.Reference Courson 21 This “safety net” is applicable for all ages, adult and children, with and without sports participation. The emergency action plan involves a written and regularly practised plan for emergency medical services (EMS) notification, effective bystander cardiopulmonary resuscitation, and the early use of an automatic external defibrillator. Coordination of all local staff with EMS personnel is critical.
Conclusions
In summary, in organised athletic events, the team physician makes the final decision regarding return to play, despite the fact that he/she is a potentially conflicted individual. Second, although extensive return-to-play protocols exist for concussions and orthopaedic injuries, similar protocols do NOT exist for cardiac conditions. Third, the existing guidelines are somewhat divergent in their recommendations – but over time there appears to be a trend to allow increased participation in athletes with cardiovascular diagnoses. A cautious use of genetic testing and information between the athlete and the physician is mandatory, as decisions cannot be made solely on the basis of a genetic test, and it is not absolute what the physician’s obligation is to the individual as opposed to the school or athletic organisation.
Acknowledgements
None.
Financial Support
This research or review received no specific grant from any funding agency or from commercial or not-for-profit sectors.
Conflicts of Interest
None.
Ethical Standards
The authors assert that all referenced work contributing to this review complies with the ethical standards of biomedical or medicolegal investigation.
