Return-to-Play for Athletes With Genetic Heart Diseases
2018; Lippincott Williams & Wilkins; Volume: 137; Issue: 10 Linguagem: Inglês
10.1161/circulationaha.117.031306
ISSN1524-4539
AutoresKari L. Turkowski, J. Martijn Bos, Nicholas C. Ackerman, Ram K. Rohatgi, Michael J. Ackerman,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 137, No. 10Return-to-Play for Athletes With Genetic Heart Diseases Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBReturn-to-Play for Athletes With Genetic Heart Diseases Kari L. Turkowski, BS, J. Martijn Bos, MD, PhD, Nicholas C. Ackerman, Ram K. Rohatgi, MD and Michael J. Ackerman, MD, PhD Kari L. TurkowskiKari L. Turkowski Mayo Clinic Graduate School of Biomedical Sciences (K.L.T.) , J. Martijn BosJ. Martijn Bos Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., R.K.R., M.J.A.) Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (J.M.B., N.C.A., M.J.A.) , Nicholas C. AckermanNicholas C. Ackerman Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (J.M.B., N.C.A., M.J.A.) , Ram K. RohatgiRam K. Rohatgi Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., R.K.R., M.J.A.) and Michael J. AckermanMichael J. Ackerman Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology (J.M.B., R.K.R., M.J.A.) Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory (J.M.B., N.C.A., M.J.A.) Department of Cardiovascular Diseases, Division of Heart Rhythm Services (M.J.A.), Mayo Clinic, Rochester, MN. Originally published6 Mar 2018https://doi.org/10.1161/CIRCULATIONAHA.117.031306Circulation. 2018;137:1086–1088Until recently, expert guidelines such as the 2005 36th Bethesda Conference Guidelines1 and the 2005 European Society of Cardiology2 guidelines have recommended disqualification from most competitive sports for athletes with a variety of genetic heart diseases, aiming to prevent sudden cardiac death. However, recent studies have shown that carefully selected athletes with a variety of genetic heart diseases, including catecholaminergic polymorphic ventricular tachycardia and long QT syndrome, who elected to continue in competitive sports after a shared decision-making evaluation rarely experienced disease-triggered breakthrough cardiac events.3–5 These observations have prompted acknowledgment of the importance of shared decision making and consideration of an athlete's desire to return-to-play in the recent 2015 American Heart Association/American College of Cardiology scientific statement.5 This document recognized that the foundational evidence to compel a recommendation for disqualification was disease-dependent and, in many instances, lacking.5 It updated the Bethesda guidelines by defining return-to-play as an approval from an expert who specializes in genetic heart diseases to participate in competitive sports after a thorough examination and a comprehensive treatment/management plan has been established. Additionally, the statement advised disclosure of the athlete's medical condition to the athlete's school/university with no guarantee that the host institution will uphold the return-to-play decision.5After approval by the Mayo Clinic Institutional Review Board, a retrospective analysis was performed for all competitive athletes with the diagnosis of a genetic heart disease evaluated at Mayo Clinic's Genetic Heart Rhythm Clinic from July 2000 to December 2015 through review of their electronic medical records, with the goal of determining return-to-play and breakthrough cardiac event outcomes as well as frequency of and reasons for participation denials. Decisions on return-to-play denial were usually obtained during follow-up visits or received via personal communication. When necessary, contact was made with the institution/organization to further clarify reasons for denial. A breakthrough cardiac event was defined as cardiogenic syncope/seizures, documented ventricular arrhythmias, aborted cardiac arrest, appropriate ventricular tachycardia– or ventricular fibrillation–terminating implantable cardioverter defibrillator shocks, and sudden cardiac death that occurred while treated and after the patient had been given approval to return-to-play. All breakthrough cardiac events that occurred in our study subjects were evaluated by an expert (M.J.A.) to determine whether the event was caused by the underlying genetic heart disease. Overall, 366 athletes (206 male [56%]) were evaluated (Figure [A]). After their evaluation, 44 patients (12%) chose to self-disqualify from athletic activity. After establishing their comprehensive treatment program, only 9/322 athletes (3%) experienced a nonlethal breakthrough cardiac event (4 of which occurred outside of sports) in 961 combined athlete-years of follow-up (0.9 event per 100 athlete-years) compared with 6 of 44 former athletes (14%) in 261 combined follow-up years (2.3 events [all nonlethal] per 100 follow-up years). In fact, Kaplan-Meier analyses showed slightly favorable outcomes for current and former athletes (log-rank P=0.03; Figure B). However, no significant differences between current compared to former athletes were observed with regard to previous symptomatic status, risk status assessment, family history of genetic heart disease, or sudden cardiac death, suggesting the level of risk was similar for both groups.Download figureDownload PowerPointFigure. Cohort demographics of 366 athletes and comparison between current and former and their breakthrough cardiac event-free survival. A, Demographics of the study cohort of 366 athletes who all received a return-to-play clearance with 322 athletes choosing to return-to-play and 44 choosing to remove themselves from their sport of choice. B, Kaplan-Meier analysis of breakthrough cardiac event-free survival of athletes and former athletes showing a significant difference between the groups (log-rank P=0.03). CPVT indicates catecholaminergic polymorphic ventricular tachycardia; Dx, diagnosis; GHD, genetic heart disease; HCM, hypertrophic cardiomyopathy; ICD, implantable cardioverter defibrillator; IVF, idiopathic ventricular fibrillation; LQTS, long QT syndrome; LV, left ventricular; LVNC, left ventricular noncompaction; PVC, premature ventricular contraction; RTP, return-to-play; and SCD, sudden cardiac death.For the majority of athletes who elected return-to-play, their return was uneventful. However, several athletes were denied participation. This denial rarely occurred for youth league, travel league, or high school varsity level athletes, but after high school it was less certain whether the institution would support return-to-play. Among 35 athletes seen in our clinic who remained active at a post–high school level, 25 (71%) reported that they had been disqualified previously by a physician or university and were seeking a reversal. After evaluation, all athletes elected return-to-play. However, despite support/evaluation by the Mayo Clinic's Genetic Heart Rhythm Clinic and discussions with the athletes and their university officials, 5 of 35 athletes (14%; 4 collegiate/1 professional) remained disqualified. In fact, 4 of 20 (20%) Division I university athletes were disqualified after receiving return-to-play clearance (none of whom experienced a breakthrough cardiac event after return-to-play). The main reasons cited for participation denial included the 2005 Bethesda Conference Guidelines (1), potential liability (3), and media exposure concerns (1).Our study demonstrated that, after implementation of a comprehensive treatment program including a shared decision regarding potential risks, athletes with genetic heart diseases can remain competitive with a reasonably low incidence of cardiac events. Furthermore, this approach does not result in universal return-to-play because athletes and their families may choose to self-disqualify. Our data show that despite growing evidence that sports continuation may be acceptably safe and despite having updated expert guidelines supporting return-to-play and the implementation of shared decision making regarding risk, athletes may still not be allowed to play based on institutional decisions. Whether return-to-play denials will decrease based on the 2015 American Heart Association/American College of Cardiology statement is unclear at the current time.Sources of FundingK.L. Turkowski received support from the Mayo Clinic Graduate School of Biomedical Sciences. N. Ackerman, K.L. Turkowski, and Drs Bos, Rohatgi, and Ackerman received support from the Windland Smith Rice Comprehensive Sudden Cardiac Death Program. Dr Ackerman received support from the Mayo Clinic Center for Individualized Medicine. This publication was supported by the Clinical and Translational Sciences Awards (grant TL1 TR000137) from the National Center for Advancing Translational Science. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.DisclosuresDr Ackerman is a consultant for and on the advisory board (modest) for Audentes Therapeutics, Boston Scientific, Gilead Sciences, Invitae, Medtronic, Myokardia, and St. Jude Medical, and has received equity/royalties (significant) from AliveCor, Blue Ox Health Corp, and Stemonix. However, none of these entities was involved in this study in any way. The other authors report no conflicts.Footnoteshttp://circ.ahajournals.orgFor patient privacy, the clinical data and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.Michael J. Ackerman, MD, PhD, Mayo Clinic's Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail [email protected]References1. Maron BJ, Zipes DP. 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Saberi S and Day S (2018) Response by Saberi and Day to Letter Regarding Article, "Exercise and Hypertrophic Cardiomyopathy: Time for a Change of Heart", Circulation, 138:3, (333-334), Online publication date: 17-Jul-2018. Schnell F, Behar N and Carré F (2018) Long-QT Syndrome and Competitive Sports, Arrhythmia & Electrophysiology Review, 10.15420/aer.2018.39.3, 7:3, (187), . March 6, 2018Vol 137, Issue 10 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.031306PMID: 29507000 Originally publishedMarch 6, 2018 Keywordshypertrophic cardiomyopathyathleteshared decision makinggenetic heart diseasedisqualificationlong QT syndromePDF download Advertisement SubjectsExerciseIon Channels/Membrane TransportSudden Cardiac Death
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