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EP LAB DIGEST. 2024;24(7):9-11.

In this discussion, Mark Link, MD, and Rachel Lampert, MD, discuss the newly released 2024 HRS expert consensus statement on arrhythmias in the athlete.  

Mark Link, MD: We are here with EP Lab Digest to discuss the new arrhythmias in the athlete consensus document¹ that is coming out today. I am here with Rachel Lampert, who is the lead author of that report. I was also one of the authors, and we have been asked to discuss the new document. So, Rachel, why did HRS decide to provide this document at this time and why do you think it was important? 

Rachel Lampert, MD: What makes our document unique is our focus on the “how,” not so much on the “if,” of athletes returning to play, which has been the focus of prior documents until now.  Instead of focusing on whether athletes can return to play, we made our goal to facilitate getting the athlete back on the field or in the pool, and doing what it is they want to do, if at all possible. So, I think that is what differentiates this document. Research on athletes with cardiovascular conditions returning to play, over the last few years has been evolving. There are a number of arrhythmogenic conditions where the conventional wisdom to be conservative and hold them back has really not borne out in studies that have looked at outcomes in athletes who have returned to play. So, while there are still many conditions where we do not know the risk, I think we are learning more, and that was one of the impetus for this document. Another impetus for this document was the growing role in medicine in general for shared decision-making. You know, that is a phrase we hear in every avenue of medicine: patient-centered care. We are now thinking about how we can apply this concept to return-to-play decisions. Mark, we have been studying athletes for a long time. Can you discuss what about an athlete is different? Why do we need a document specifically about management of arrhythmias in the athlete?

Link: I will answer that, but first I want to go back to your shared decision-making comment because I think that is crucial. I have been involved in these guidelines for 20 to 25 years now, and when I got started, it used to be a very paternalistic, MD-based decision. The physician made the decision whether or not the athlete could go back to sports, and that was true even in the 2015 document. But there has been a world of change in shared decision-making, and now the athletes and their families are included in that decision. I think that has been not only a huge change, but a needed change. So, there are a couple of things that are different about athletes. They work at a premium on sports and testing their bodies, so they are really pushing their bodies to the limit where most people do not. I think the other thing is that if an athlete experiences syncope or even sudden cardiac arrest on the field, it immediately becomes a media event. If it happens at home or at night, it is not going to be as much a media event. So, I think when people see these athletes experiencing events on the field, they worry about the mortality of the athletes and their own mortality. 

Lampert: I agree those are important aspects, and some of the treatments that we use—pharmacologic, palliative, and device treatments—impact the athlete differently depending on what kind of demands they want to put on their body, including how medications may impact their sport. It is another reason why athletes need to be assessed differently. 

Link: Yes, the athlete is also different because they want to return to their sport. If you are not an athlete, an implantable cardioverter-defibrillator (ICD) will still be a big impact, but the athlete really wants to get back to play. Let’s get back to the main goal of this document. What was the goal? 

Lampert: Our goal was to facilitate that life choice that so many athletes want, which is to get back into the game. There are some conditions where data does suggest sports are dangerous, but for the most part, the data suggest this is something we can talk about. For many conditions, the risks are not necessarily zero, but they are likely low, which we can talk about with patients. Facilitating the athlete’s ability to take control of their own lives, make decisions, and have the life they want was really one of the goals of the document. 

Link: Right, and I want to second that. The goal was really to try to get the athlete back into sports, not keep them from sports. That is a different goal than many of the other documents that we have dealt with before when talking about athletes. 

Lampert: Yes, I think that is really critical. So, Mark, share with us some of these things to think about as we focus on getting athletes back into the game. 

Link: Most of our athletes that we are talking about have underlying cardiac conditions and have had arrhythmias, including sudden cardiac arrest. So, what we need to do is focus on their safety and appropriately treat their arrhythmias with medications, pharmacology, or surgery to make it safe for them to get back to play. 

Lampert: How do we know when we are at that goal? 

Link: As you mentioned before, you are never 100% sure, but no one is ever 100% sure that they won’t have a cardiac arrest as they are walking out of the stadium. So, as part of this document, we discussed how to get to that goal. Exercise testing as appropriate to the type of sports they are doing is very important. For some athletes, that may include monitoring such as wearable monitors or even implantable loop recorders. In athletes who will need an ICD, it is ensuring that they can do the appropriate level of stress with their ICD without getting shocked. So, this document talks about testing athletes to get them back to play. 

Lampert: How do you manage stress testing? What do you suggest? 

Link: For most of us, we do not have Ben Levine’s swimming pool to test a swimmer. But what we want to do is stress them in what they are going to do. So, for a long-distance runner, you would put them up to whatever speed they are going to go and keep them on the treadmill for 30 minutes. For a sprinter, you are going to go up much faster. So, you are going to really try to recreate their condition in sports. 

Lampert: You are talking about a sport-specific protocol.

Link: Yes.

Lampert: Then, you are setting them off at top speed. So, people really need to tailor that stress test to the athlete and sport and disease.

Link: Right, and then you must acknowledge that one stress test is not necessarily going to do everything. That is why some athletes will need extended monitoring as they return to sports. That monitoring could be something as simple as a patch or more complicated such as an implantable monitor. 

Lampert: Let’s talk about some of the specific disease entities that we covered. Where do you want to start? 

Link: We covered almost every disease you could think of. One of the diseases that we focused on was arrhythmogenic right ventricular dysplasia, because that is one of the more common causes of sudden death in sports. It is also the disease that we have the best evidence that sports and excessive exercise worsens the condition as well as the risk for sudden cardiac death. So, for individuals with that disease, we really did not want them to engage in competitive or aggressive sports. But again, that is the disease that we have the most data on. We have far more patients with hypertrophic cardiomyopathy (HCM), so let’s talk about that. What is the data on HCM patients returning to sports? Also, I want you to mention that in this document, we gave it a 2A, while in the American Heart Association/American College of Cardiology document, it was given a 2B. 

Lampert: As you know well, Mark, patients with HCM have been restricted from sports for decades. That was really based on a series of athletes who died suddenly, which as we know, cannot be extrapolated to a diagnosed population. There are increasing data that individuals with HCM who do go back to play, after appropriate risk assessment and treatment, do not have an excessive risk. These data include the prospective LIVE-HCM study, which compared vigorous exercisers (including competitive) to the non-vigorous, as well as a recent series of elite athletes that included many with HCM, and several other series of athletes with HCM from Italy and the UK. In our document, which addressed many disease entities, we looked at what data were there in the relevant population of athletes returning to play—was there evidence of harm or suggestion of lack of harm—and for HCM, given that the data in athletes with HCM who have returned to play was not showing harm, we gave that a 2A as we did for other similar entities. The AHA’s HCM guidelines  gave it a 2B. I think it is really important, though, to focus on the similarities between our section on HCM and theirs. We both talk about the importance of expert assessment, making sure that the HCM athlete has met with a cardiologist who really understands risk assessment in HCM. We talked about the importance of expert assessment, and we talked about the importance of shared decision-making as well as emergency action planning. I think what makes a 2A versus a 2B in return to play is not firmly defined. The similarities between the two are more important than the differences. 

Link: Another one of the similarities between the two is that both acknowledge that the patient with HCM should exercise and not be a couch potato. So, they both acknowledge a part on preventative, but both wanted HCM patients to exercise.

Lampert: Yes, and I think based on the RESET-HCM study, we know that individuals with HCM who exercise feel better. 

Link: Yes, they feel better, have a better quality of life, and higher VO2 on stress testing without an increase in danger. 

Lampert: What other disease entities would you like to talk about? 

Link: Those are probably the 2 most common ones, but again, we touched in this document on Wolff-Parkinson-White syndrome, and WPW patients are also at risk for sudden death even if they have never had sudden death. So, we talked about the appropriate screening for patients with WPW and treatment. We also talked about pacemakers and defibrillators as well as the types of pacemakers and defibrillators. Programming of pacemakers and defibrillators is also very important, because younger athletes with these devices can get their heart rate much higher than the kinds of patients we are used to dealing with, which are patients with ischemic cardiomyopathies.

Lampert: This is one area where the management aspect of this document is so important. How do you program the ICD or pacemaker to make sure that they do not lose AV synchrony, such as a congenital patient with post-surgical heart block? 

Link: Another part of this document that I think is so helpful is the algorithms. There is an algorithm for the workup of a patient with sudden cardiac death, which I do not think I have ever seen before in any guideline. There is an algorithm for workup of a patient with syncope. There is an algorithm for a workup of a patient with both benign ventricular arrhythmias and complex or serious arrhythmias. I think those algorithms are going to be used in a lot of talks and by a lot of patients and physicians. So, to finish this up, one other thing we talked about in this document was emergency action plans, which I think is a big part of the care of our patients. What can you tell us about that? 

Lampert: That is something that we see in action, including when athletes sometimes go into cardiac arrest on TV. We see that emergency plan in action after cardiac arrest and how important it is for the athlete’s survival. The electrophysiologist is not always the person in charge of emergency action plans, but I think having our field involved in that and working with the sports medicine teams in schools is critical. 

Link: Yes, and you can see the difference that an emergency action plan makes, like in Damar Hamlin. They were out there immediately doing cardiopulmonary resuscitation (CPR) and defibrillation, and he walked out of the hospital 2 weeks later.

Lampert: Yes, it was so heartening to see. 

Link: It really makes a difference. Again and again, we are hearing this in the community: early CPR and defibrillation with early transport to the hospital makes a big difference. 

Lampert: Well, thank you and EP Lab Digest for this opportunity. It is great to have a chance to talk about this, see this document from start to fruition, and have a chance to talk about it.

Link: Great, and it is coming out today. And yes, thanks to EP Lab Digest for having us here to talk about this document, which we think is very important.

The transcripts have been edited for clarity and length.

Reference

1. Lampert R, Chung EH, Ackerman MJ, et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm. 2024:S1547-5271(24)02560-8. doi:10.1016/j.hrthm.2024.05.018