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Medical Evaluation of Athletes: Genetic Testing

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Textbook of Sports and Exercise Cardiology

Abstract

Sports Cardiology practice commonly involves evaluation of athletes for genetically determined cardiac conditions that predispose to exercise-induced malignant arrhythmias and sudden cardiac death (SCD). Differentiation of “athlete’s heart” from heart disease may be challenging due to the effects of exercise on the electrical and structural cardiac remodeling; prolongation of the QT interval, left ventricular hypertrophy and cavity dilatation create significant overlap between physiology and inherited channelopathies and cardiomyopathies also known as the “grey zone”. Genetic studies over the last 30 years have identified gene abnormalities that underpin these conditions. In addition, technological advances have made genetic testing a more readily available and cheaper tool, raising questions relating to its exact role in the investigation of athletes. Before considering genetic testing, the athlete should have appropriate genetic counselling relating to the potential implications of the result on the athlete and their family, as well as the challenges and limitations of the testing. Genetic testing in an athlete can have diagnostic, prognostic and therapeutic implications, including guiding exercise recommendations. The yield of genetic testing varies depending on the condition under assessment and importantly, is significantly lower for athletes with borderline phenotypes (“grey zone”). Genetic testing results are not binary but there is a probabilistic spectrum of pathogenicity. To avoid confusion, accurate assessment of the information is required by individuals with expertise in cardio-genetics, using established scoring criteria.

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Author information

Authors and Affiliations

  1. Cardiology Clinical Academic Group, St George’s, University of London, London, UK

    Belinda Gray & Michael Papadakis

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  1. Belinda Gray
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  2. Michael Papadakis
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Corresponding author

Correspondence to Michael Papadakis .

Editor information

Editors and Affiliations

  1. Private Center for Sports and Exercise Cardiology, München, Bayern, Germany

    Axel Pressler

  2. University Institute of Sports Medicine Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria

    Josef Niebauer

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1.1 Questions

  1. 1.

    An 18-year-old professional football player is identified to have a QTc of 490 ms on ECG screening. Which of the following statements is true regarding genetic testing?

    1. a.

      A variant of uncertain significance in KCNQ1 (LQT1) is an indication to commence betablocker therapy

    2. b.

      Genetic testing in this athlete has no prognostic value as the QTc is <500 ms

    3. c.

      Genetic testing is not recommended as the diagnosis is not confirmed

    4. d.

      Genetic testing with a long QT panel may help to differentiate congenital long QT syndrome from athletic ECG adaptation

    5. e.

      The athlete should defer genetic testing to prevent disqualification from competitive football

  2. 2.

    A 45-year-old man presents following the unexplained sudden death of his younger brother on the football field, aged 35 years old. The deceased had undergone a negative postmortem and DNA was stored. Which of the following statements is true?

    1. a.

      Genetic testing for inherited arrhythmia syndromes can be considered in the deceased’s DNA

    2. b.

      Genetic testing for inherited arrhythmia syndromes is indicated in the living 45-year-old brother

    3. c.

      Genetic testing should be performed in the brother and the deceased proband DNA concurrently

    4. d.

      Genetic testing should not be considered in the deceased’s DNA as the postmortem is negative

    5. e.

      The DNA should be stored for research in the future, but no genetic testing should be performed at present

  3. 3.

    Which of the following statements regarding cascade family genetic testing is correct for an athlete with a diagnosis of HCM?

    1. a.

      All family members who undergo negative clinical screening based on ECG and echo should be referred for diagnostic genetic testing.

    2. b.

      First degree family members should be offered extensive genetic panel testing regardless of presence or absence of symptomatology

    3. c.

      First degree family members with cardiac symptoms or signs suggestive of HCM should be offered extensive genetic panel testing

    4. d.

      If a likely pathogenic variant is found in the athlete, targeted (predictive) genetic testing of all first-degree family members is recommended

    5. e.

      If a VUS is found in the athlete, genetic testing of all first-degree family members is recommended to determine its significance

1.2 Answers

  1. 1.

    D: In an athlete with borderline QTc prolongation (480–500 ms), genetic testing for LQT 1–3 may assist in clarifying the diagnosis. In addition, by confirming the diagnosis in the athlete potentially lifesaving betablocker therapy can be initiated.

    A is not correct as variants of uncertain significance should not lead to an alteration in athlete’s management [1].

    B is not correct, data shows the greater the QTc interval the higher the potential risk to the individual [10].

    C is not correct, genetic testing is indicated in this situation as it can assist in confirming the diagnosis [1].

    E is not correct, genetic testing can help facilitate appropriate therapy and return to play [58, 59].

  2. 2.

    A: HRS/EHRA guidelines state that an arrhythmia syndrome focused post mortem genetic testing “molecular autopsy” can be considered (Class IIa) [1].

    B is not correct, if DNA is stored on the deceased (the proband) then genetic testing should be initiated in them in the first instance. The brother should undergo clinical screening, and if there is evidence in him of an inherited cardiac condition then directed genetic testing can be ordered.

    C is not correct, usually the testing is initiated in the proband in the first instance (as above).

    D is not correct, a number of inherited cardiac conditions may present with sudden death as the first symptom, particularly channelopathies which are associated with a structurally normal heart [56].

    E is not correct, if DNA is stored then genetic testing for molecular autopsy should be initiated especially as the inherited cardiac conditions are autosomal dominant and therefore first degree family members have a 50% chance of having the same condition [1, 56].

  3. 3.

    D: Class I indication in EHRA/HRS guidelines with regards to genetic screening of first-degree relatives following a pathogenic variant being identified in an individual with hypertrophic cardiomyopathy.

    A/B/C are not correct as genetic testing should not be performed in family members in the first instance without a genetic diagnosis in the index case, independent of symptomatology. Clinical testing should be performed in all first-degree family members. The proband (i.e. the first person diagnosed in the family) is tested first whenever possible, and predictive testing is only offered to family members for likely pathogenic or pathogenic variants. Therefore, only the athlete should be tested genetically for known HCM genes in the first instance. If an actionable gene result is identified in the athlete this can then be used for predictive testing in the first-degree family members, independent of their clinical phenotyping.

    E is not correct. A variant of uncertain significance is not an actionable genetic variant [4].

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Gray, B., Papadakis, M. (2020). Medical Evaluation of Athletes: Genetic Testing. In: Pressler, A., Niebauer, J. (eds) Textbook of Sports and Exercise Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-030-35374-2_11

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