Treatment of athletes with cardiac disease or arrhythmias

  • Amil M. Shah
  • N. A. Mark Estes
  • Jonathan Weinstock
  • Munther K. Homoud
  • Mark S. Link
Article
  • 55 Downloads

Opinion statement

Ventricular arrhythmias and sudden cardiac death in the athlete are uncommon but extremely visible because of the high profile of amateur and professional athletes. In athletes under the age of 30 years, the incidence of sudden death is low and in most cases occurs in individuals with inherited heart disease. In the older athlete, sudden death is more common and is generally due to arrhythmias in the context of coronary artery disease. Many athletes with aborted sudden death, arrhythmia-related syncope, or high-risk genetic disorders benefit from therapy with implantable cardioverterdefibrillators (ICDs). Although ICD therapy can effectively abort sudden death, implantation of an ICD generally prohibits an individual from all competitive athletics except low-intensity sports. Recommendations for participation in competitive athletics generally follow the recently published 36th Bethesda Conference Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Maron BJ, Douglas PS, Graham TP, et al: Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol 2005, 45:1322–1326. Most recent guidelines for the evaluation and management of competitive athletes with cardiac abnormalities. Detailed evidence-based recommendations for sports participation eligibility.PubMedCrossRefGoogle Scholar
  2. 2.
    Mitchell JH, Haskell W, Snell P, Van Camp SP: Task Force 8: classification of sports. J Am Coll Cardiol 2005, 45:1364–1367.PubMedCrossRefGoogle Scholar
  3. 3.
    Maron BJ: Cardiovascular risks to young persons on the athletic field. Ann Intern Med 1998, 129:379–386.PubMedGoogle Scholar
  4. 4.
    Corrado D, Basso C, Rizzoli G, et al: Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 2003, 42:1959–1963. Comprehensive 21-year cohort study of sudden death among all young people in the Veneto region of Italy. Described ARVD as an unusually prevalent cause of SCD in this population.PubMedCrossRefGoogle Scholar
  5. 5.
    Maron BJ, Gardin JM, Flack JM, et al: Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Echocardiographic analysis of 4111 subjects in the CARDIA Study. Coronary Artery Risk Development in (Young) Adults. Circulation 1995, 92:785–789.PubMedGoogle Scholar
  6. 6.
    Corrado D, Basso C, Schiavon M, Thiene G: Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998, 339:364–369.PubMedCrossRefGoogle Scholar
  7. 7.
    Pelliccia A, Maron BJ, Culasso F, et al: Clinical significance of abnormal electrocardiographic patterns in trained athletes. Circulation 2000, 102:278–284.PubMedGoogle Scholar
  8. 8.
    Talan DA, Bauernfeind RA, Ashley WW, et al: Twentyfour hour continuous ECG recordings in long-distance runners. Chest 1982, 82:19–24.PubMedGoogle Scholar
  9. 9.
    Swygman C, Wang PJ, Link MS, et al: Advances in implantable cardioverter defibrillators. Curr Opin Cardiol 2002, 17:24–28.PubMedCrossRefGoogle Scholar
  10. 10.
    Zehender M, Meinertz T, Keul J, Just H: ECG variants and cardiac arrhythmias in athletes: clinical relevance and prognostic importance. Am Heart J 1990, 119:1378–1391.PubMedCrossRefGoogle Scholar
  11. 11.
    Douglas PS, O’Toole ML, Hiller WD, et al: Electrocardiographic diagnosis of exercise-induced left ventricular hypertrophy. Am Heart J 1988, 116:784–790.PubMedCrossRefGoogle Scholar
  12. 12.
    Balady GJ, Cadigan JB, Ryan TJ: Electrocardiogram of the athlete: an analysis of 289 professional football players. Am J Cardiol 1984, 53:1339–1343.PubMedCrossRefGoogle Scholar
  13. 13.
    Brugada P, Green M, Abdollah H, Wellens HJJ: Significance of ventricular arrhythmias initiated by programmed ventricular stimulation: the importance of the type of ventricular arrhythmia induced and the number of premature stimuli required. Circulation 1984, 69:87–92.PubMedGoogle Scholar
  14. 14.
    Link MS, Saeed M, Gupta N, et al: Inducible ventricular flutter and fibrillation predict for arrhythmia occurrence in coronary artery disease patients presenting with syncope of unknown origin. J Cardiovasc Electrophysiol 2002, 13:1103–1108.PubMedCrossRefGoogle Scholar
  15. 15.
    Peters S, Reil GH: Risk factors of cardiac arrest in arrhythmogenic right ventricular dysplasia. Eur Heart J 1995, 16:77–80.PubMedGoogle Scholar
  16. 16.
    Corrado D, Leoni L, Link MS, et al: Implantable cardioverter-defibrillator therapy for prevention of sudden death in patients with arrhythmogenic right ventricular cardiomyopathy/dysplasia. Circulation 2003, 108:3084–3091. Multicenter study of impact of ICD therapy in 132 patients with mostly symptomatic ARVC. Over a mean follow-up of 39 months, it was found 24% had VT/VF that would likely have been fatal. It noted that programmed ventricular stimulation had limited use in identifying patients at risk of ventricular arrhythmias.PubMedCrossRefGoogle Scholar
  17. 17.
    Brugada J, Brugada R, Brugada P: Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest. Circulation 2003, 108:3092–3096. Study of individuals with Brugada syndrome and no previous cardiac arrest that demonstrates a high risk of sudden death. Inducibility of ventricular arrhythmias and a previous history of syncope are markers of a poor prognosis.PubMedCrossRefGoogle Scholar
  18. 18.
    Link MS, Wang PJ, Estes III NAM: Cardiac arrhythmias and electrophysiologic observations in the athlete. In In The Athlete and Heart Disease. Edited by Williams RA, Williams R. Philadelphia: Lippincott Williams & Wilkins; 1998:197–216.Google Scholar
  19. 19.
    Maron BJ: Sudden death in young athletes. N Engl J Med 2003, 349:1064–1075. Comprehensive review of SCD among young athletes. Includes data from the Minneapolis Heart Institute Foundation registry, which demonstrated HCM as the most prevalent cardiovascular abnormality underlying sudden death among US young athletes.PubMedCrossRefGoogle Scholar
  20. 20.
    Puranik R, Chow CK, Duflou JA, et al: Sudden death in the young. Heart Rhythm 2005, 2:1277–1282. A 10-year retrospective review of all sudden death cases among young persons in a section of Sydney, Australia. Investigators found a significant proportion of deaths were associated with structurally normal hearts at autopsy in contrast to the United States and Italian experience. These results suggest that in this population SCD secondary to channelopathies may be more common than previously expected.PubMedCrossRefGoogle Scholar
  21. 21.
    Ellsworth EG, Ackerman MJ: The changing face of sudden cardiac death in the young. Heart Rhythm 2005, 2:1283–1285.PubMedCrossRefGoogle Scholar
  22. 22.
    Maron BJ, Ackerman MJ, Nishimura RA, et al: Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome. J Am Coll Cardiol 2005, 45:1340–1345.PubMedCrossRefGoogle Scholar
  23. 23.
    Frenneaux MP: Assessing the risk of sudden cardiac death in a patient with hypertrophic cardiomyopathy. Heart 2004, 90:570–575. Excellent review of risk assessment for patients with HCM. Reviews the data for individual risk factors and discusses the use of global risk burden for SCD in the management of patients.PubMedCrossRefGoogle Scholar
  24. 24.
    Pelliccia A, Culasso F, Di Paolo FM, Maron BJ: Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med 1999, 130:23–31.PubMedGoogle Scholar
  25. 25.
    Pelliccia A, Maron BJ, Spataro A, et al: The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med 1991, 324:295–301.PubMedCrossRefGoogle Scholar
  26. 26.
    Maron BJ: Distinguishing hypertrophic cardiomyopathy from athlete’s heart: a clinical problem of increasing magnitude and significance. Heart 2005, 91:1380–1382.PubMedCrossRefGoogle Scholar
  27. 27.
    Maron BJ, Chaitman BR, Ackerman MJ, et al: Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation 2004, 109:2807–2816.PubMedCrossRefGoogle Scholar
  28. 28.
    Elliott PM, Blanes JRG, Mahan NG, et al: Relation between severity of left-ventricular hypertrophy and prognosis in patients with hypertrophic cardiomyopathy. Lancet 2001, 357:420–424.PubMedCrossRefGoogle Scholar
  29. 29.
    Hulot JS, Jouven X, Empana JP, et al: Natural history and risk stratification of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Circulation 2004, 110:1879–1884. Retrospective study of 130 patients with ARVC using logistic regression to determine risk factors for cardiovascular death. Mean follow-up was 8.1 years. When established risk factors were controlled for, RV failure and LV dysfunction remained significant predictors of cardiovascular mortality.PubMedCrossRefGoogle Scholar
  30. 30.
    Roguin A, Bomma CS, Nasir K, et al: Implantable cardioverter-defibrillators in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy. J Am Coll Cardiol 2004, 43:1843–1852. Cohort study of 42 patients with ARVC undergoing ICD implantation with a mean follow-up of 42 months. A total of 78% received appropriate ICD interventions. Predictors of appropriate firing included induction of sustained VT during electrophysiologic study, detection of spontaneous VT, and severe RV dilation.PubMedCrossRefGoogle Scholar
  31. 31.
    Wichter T, Paul M, Wollmann C, et al: Implantable cardioverter/defibrillator therapy in arrhythmogenic right ventricular cardiomyopathy: single-center experience of long-term follow-up and complications in 60 patients. Circulation 2004, 109:1503–1508. Prospective cohort study of ICD implantation in 60 patients with ARVC. Demonstrated a high frequency of potentially fatal VT by 7 years after implantation (44%). Also noted a significant frequency of lead-related complications by 7 years after implantation (37%).PubMedCrossRefGoogle Scholar
  32. 32.
    Zipes DP, Ackerman MJ, Estes NA 3rd, et al: Task Force 7: arrhythmias. J Am Coll Cardiol 2005, 45:1354–1363.PubMedCrossRefGoogle Scholar
  33. 33.
    Corrado D, Basso C, Poletti A, et al: Sudden death in the young. Is acute coronary thrombosis the major precipitating factor? Circulation 1994, 90:2315–2323.PubMedGoogle Scholar
  34. 34.
    Thompson PD, Balady GJ, Chaitman BR, et al: Task Force 6: coronary artery disease. J Am Coll Cardiol 2005, 45:1348–1353.PubMedCrossRefGoogle Scholar
  35. 35.
    Basso C, Corrado D, Thiene G: Congenital coronary artery anomalies as an important cause of sudden death in the young. Cardiol Rev 2001, 9:312–317.PubMedCrossRefGoogle Scholar
  36. 36.
    Graham TP Jr, Driscoll DJ, Gersony WM, et al: Task Force 2: congenital heart disease. J Am Coll Cardiol 2005, 45:1326–1333.PubMedCrossRefGoogle Scholar
  37. 37.
    Wellens HJ: Should catheter ablation be performed in asymptomatic patients with Wolff-Parkinson-White syndrome? When to perform catheter ablation in asymptomatic patients with a Wolff-Parkinson-White electrocardiogram. Circulation 2005, 112:2201–2207;discussion 2216. Well-reasoned discussion of the workup and management of asymptomatic patients with WPW syndrome.PubMedCrossRefGoogle Scholar
  38. 38.
    Pappone C, Santinelli V: Should catheter ablation be performed in asymptomatic patients with Wolff-Parkinson-White syndrome? Catheter ablation should be performed in asymptomatic patients with Wolff-Parkinson-White syndrome. Circulation 2005, 112:2207–2215; discussion 2216. Discussion in which the authors point to the higher than previously thought risk of sudden death in asymptomatic individuals with WPW syndrome, and argue for a more aggressive approach.PubMedGoogle Scholar
  39. 39.
    Chugh SS, Senashova O, Watts A, et al: Postmortem molecular screening in unexplained sudden death. J Am Coll Cardiol 2004, 43:1625–1629.PubMedCrossRefGoogle Scholar
  40. 40.
    Tester DJ, Spoon DB, Valdivia HH, et al: Targeted mutational analysis of the RyR2-encoded cardiac ryanodine receptor in sudden unexplained death: a molecular autopsy of 49 medical examiner/coroner’s cases. Mayo Clin Proc 2004, 79:1380–1384.PubMedCrossRefGoogle Scholar
  41. 41.
    Kass RS, Moss AJ: Long QT syndrome: novel insights into the mechanisms of cardiac arrhythmias. J Clin Invest 2003, 112:810–815.PubMedCrossRefGoogle Scholar
  42. 42.
    Schwartz PJ, Priori SG, Spazzolini C, et al: Genotypephenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias. Circulation 2001, 103:89–95.PubMedGoogle Scholar
  43. 43.
    Tester DJ, Will ML, Haglund CM, Ackerman MJ: Effect of clinical phenotype on yield of long QT syndrome genetic testing. J Am Coll Cardiol 2006, 47:764–768.PubMedCrossRefGoogle Scholar
  44. 44.
    Vyas H, Hejlik J, Ackerman MJ: Epinephrine QT stress testing in the evaluation of congenital long-QT syndrome: diagnostic accuracy of the paradoxical QT response. Circulation 2006, 113:1385–1392.PubMedCrossRefGoogle Scholar
  45. 45.
    Moss AJ, Zareba W, Hall WJ, et al: Effectiveness and limitations of beta-blocker therapy in congenital long-QT syndrome. Circulation 2000, 101:616–623.PubMedGoogle Scholar
  46. 46.
    Antzelevitch C, Brugada P, Borggrefe M, et al: Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005, 111:659–670. Consensus guidelines for the evaluation and management of patients with or suspected of having Brugada syndrome. Reviews diagnosis and electrophysiology mechanisms of this disorder. Also suggests an algorithm for SCD risk assessment and ICD implantation.PubMedCrossRefGoogle Scholar
  47. 47.
    Priori SG, Napolitano C, Gasparini M, et al: Natural history of Brugada syndrome: insights for risk stratification and management. Circulation 2002, 105:1342–1347.PubMedCrossRefGoogle Scholar
  48. 48.
    Eckardt L, Probst V, Smits JP, et al: Long-term prognosis of individuals with right precordial ST-segmentelevation Brugada syndrome. Circulation 2005, 111:257–263. Study of 212 patients with Brugada syndrome followed for an average of 40 months. Predictors of adverse outcome included spontaneous type 1 ECG and a history of aborted SCD or syncope.PubMedCrossRefGoogle Scholar
  49. 49.
    Gaita F, Giustetto C, Bianchi F, et al: Short QT syndrome: a familial cause of sudden death. Circulation 2003, 108:965–970.PubMedCrossRefGoogle Scholar
  50. 50.
    Link MS, Wang PJ, Pandian NG, et al: An experimental model of sudden death due to low-energy chest-wall impact (commotio cordis). N Engl J Med 1998, 338:1805–1811.PubMedCrossRefGoogle Scholar
  51. 51.
    Link MS: Mechanically induced sudden death in chest wall impact. Prog Biophys Mol Biol 2003, 82:175–186.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2006

Authors and Affiliations

  • Amil M. Shah
  • N. A. Mark Estes
  • Jonathan Weinstock
  • Munther K. Homoud
  • Mark S. Link
    • 1
  1. 1.Cardiac Arrhythmia Service, Division of CardiologyTufts-New England Medical CenterBostonUSA

Personalised recommendations