Shocking News: Athletic Patients With ICDs Pose Complex Management Issues

Case Presentation

Our patient is a 17-year-old competitive, successful, high school basketball player with a full athletic University scholarship. During a game in his senior year of high school, he had sudden collapse on the basketball court. Dumbfounded witnesses did not know what to do but his father, a science teacher, attempted to resuscitate his son. The paramedics arrived and multiple external defibrillation shocks restored him to sinus rhythm. He remained comatose for several days before wakening in the hospital. Complete cardiac evaluation including echocardiography, cardiac catheterization, electrophysiology study, myocardial biopsy, toxicology screen and other tests were unremarkable. The patient had mild ventricular hypertrophy by echocardiography within the range of normal for an athlete. Based on his cardiac arrest, as indicated by the AVID trial, an implantable cardioverter-defibrillator (ICD) was placed. When arriving at the University, officials refused to allow him to play even though he had obtained a full athletic scholarship. The decision was based on the opinion that playing basketball with an ICD is unsafe, as stated in the Bethesda Guidelines¹ and NASPE recommendations.² In a suit filed against the University under the Federal Disabilities Act, a lower court deemed the athlete was fit to compete. This decision was overturned on appeal. The judge stated that the University had the right to choose its own experts that restricted the athlete as long as they followed accepted guidelines. The athlete ultimately went to another University where he continued to play competitive basketball. He became team captain, leading the team in three-point shooting, free throw shooting, and grade point average.

Discussion

This case illustrates several important points, later the focus of a New England Journal of Medicine article³ outlining the questions raised: (1) Competitive athletes can be highly motivated and want to continue to compete at all costs even if there is a risk for sudden death; (2) Data on the safety of competing in athletic sports such as basketball with an ICD is lacking; and (3) The efficacy of the ICD and the effect of ICD shocks during competitive sports is unknown. The Bethesda Guidelines¹ on sports participation, now in the process of being revised, consider that the risk to compete athletically with an ICD is unacceptably high. The guidelines indicate that individuals with an ICD should not be involved in sports more active than bowling and golf (even though these also have not been shown to be safe either) regardless of the underlying structural heart disease. These guidelines are based on expert opinions, as data on this population are limited and generally speculative. The real risk of sports participation with an ICD and the excess risk of a ventricular arrhythmia with competitive athletic activity are unknown. It is possible that an athlete with an ICD under intense stress of athletics may have an episode of ventricular tachycardia or sinus tachycardia and may receive an appropriate or inappropriate shock. Whether the ICD would be efficacious under these circumstances is open to question. There is also a risk of damage to the device and leads. For example, a lead fracture or an insulation break may occur from intense upper extremity exercise that is part of the basketball game. There is the risk that the patient may have recurrent episodes of ventricular tachycardia and receive multiple shocks during the intensity of exercise. The extent to which these risks may occur has not been described. Further, whether the intensity of the sport may contribute to a potential adverse outcome is unknown. Another issue relates to the underlying medical condition. Whether or not an ICD is present, a patient with hypertrophic cardiomyopathy should not participate competitively. However, the type of activity that is safe and acceptable for such an individual is not known. On the other hand, one of the goals of ICD therapy is to allow patients to liberalize their activity and to go back to activities that they enjoy. The love of many athletes for their sports is probably beyond the understanding of most physicians. Ultimately, the patient will weigh the potential risks and benefits and make his own choice. For the physician, however, there are multiple issues that make it difficult to allow a patient with an ICD to return to sports. Presently, a team basketball player at the University of Washington has an ICD and has returned to competitive sports after she made it clear that she is taking full responsibility for her actions and is willing to accept any consequences. While her commitment may not hold up in court if she dies, it is likely we will be seeing more and more of these individuals, especially as more and more ICDS are implanted for prophylactic purposes, such as for people with congenital syndromes who have few overt symptoms but are at risk of sudden cardiac death. Would it be proper to restrict an individual who has, for example, long QT interval syndrome and an ICD, but has never had a severe symptom? These two cases highlight the need for sports physicians and electrophysiologists to understand the risks for an athlete with an ICD to return to sports, and the motivations and thinking of these competitive players. Athletes tend to be young and often otherwise healthy. This topic has led to heated, vitriolic discussions in many arenas. The issues regarding who, if anyone, with an ICD can compete in sports remains unresolved. One thing does appear to be clear: there is a difference of opinion amongst electrophysiologists regarding who can and cannot participate in sports activities. We performed a survey amongst Heart Rhythm Society (NASPE/HRS) members to explore the opinions of electrophysiologists who implant and treat patients with ICDs to determine what actually is occurring in clinical practice around the United States.⁴ In this mail-in survey, we did receive a substantial (> 40%) response. We are presently in the process of deciphering the implications of the survey. Preliminary data were presented at the American Heart Association. Clearly, recommendations among physicians and practices among patients vary widely. Recommendations do not always follow the Bethesda Guidelines. These athletes, and our recent survey, underscore a crucial issue with which we in the electrophysiology community must deal on a regular basis, that is, the balance between sanctioning activities that our patients find necessary and enjoyable and at the same time protecting them and others. Sports participation is rarely if ever completely safe even without an ICD. The practice of medicine requires careful assessment of all the information available from the patient, from the literature and from medical and life experiences. Currently there are there are few data to substantiate or contradict the need for the current restrictions. Prospective studies are needed to guide recommendations. The best care involves choices made by the patient, by the family and by those also influenced by the care of the patient. In an attempt to do the right thing, some may be unfairly restricted or instead given too much freedom. Differences of opinion are part of the process, and risk to the patient and to the profession exist. To make a proper decision, it becomes necessary to know the desires, fears, needs and hopes of the patient. Who has the right to take away individual choice? In medicine, physicians frequently do this under the rubric of protecting the patient. This happens often, and is frequently based on little, if any, data. The issues are more complex than they first appear, especially in a patient who is highly visible. Until further data is available, as stated in the decision of the judge in our patient's case, it is best that this decision is left to the best medical reasoning possible rather than a court of law. For more information, please visit https://www.faculty.piercelaw.edu/ redfield/library/Pdf/case-knapp.northwestern.pdf.