Sports Participation in Athletes with Heart Disease (ACCEL): Are the Guidelines Too Strict?
What's the take-away message from current US and European guidelines on sports participation for competitive athletes with CV abnormalities? Michael John Ackerman, MD, PhD, thinks the message in a word is: No. In the case of the 1994 ACC Bethesda Conference Report on this topic, for example, he summarizes its message thusly: "Unless your heart is perfect, no competitive sports period."1
As for the current European Society of Cardiology (ESC) guidelines and the 2005 Bethesda Conference Report,2,3 the message is only a little more nuanced, he said. Quoting Dr. Ackerman, a participant and co-author of the updated Bethesda Conference Report, the two documents essentially say: "Unless your heart is perfect or the syndrome is confined to just your genome … no competitive sports except perhaps class 1A sports."
Using the recommendations relating to individuals with congenital long QT syndrome (LQTS) as an example, he said, the 36th Bethesda Conference Guidelines, advised disqualification from almost all sports (except class 1A sports) for patients with:
- history of symptoms
- asymptomatic baseline ECG with QTc >470 ms (males) or >480 ms (females)
However, genotype positive/phenotype negative LQTS patients are OK to play (other than LQT1 individuals who should avoid swimming).
(So, what are class 1A sports? Examples include billiards, bowling, cricket, curling, golf, and riflery.) The ESC guidelines advise disqualification from all competitive sports for any LQTS patient, symptomatic or asymptomatic. As for exercise positive/phenotype negative patients, it is not OK for them to play either.
In other words, he said, according to the ESC, the appropriate message for sports participants determined to have congenital LQTS is: "Forget about it! Manifest or concealed, you are done. Gene carriers, you are done."
Art Not Science
One big problem, he said, is the basis for the current recommendations. He pointed to the introduction of the 36th Bethesda Conference Report wherein the co-chairs wrote: "The present consensus recommendations were necessarily based largely on individual and collective judgments and the experience of the panel, as well as on the available pertinent scientific data. Indeed, in the process of formulating the recommendations, the panel participants, who are cardiovascular authorities most comfortable with a high level of precision, were often required to confront areas in which there was a paucity of hard evidence and utilize the 'art of medicine' in designing recommendations."
They also acknowledge the guidelines "will occasionally cause some athletes to be withdrawn from competition unnecessarily."
Consider the guidelines approach, which he calls, "if in doubt, kick 'em out," to the Mayo Clinic's LQTS clinic philosophy: respect patient/family autonomy and their right to make a decision. Based on the limited evidence that underlies the current expert opinion guidelines regarding competitive sports participation for athletes with heart disease, he said, there is a need to reconsider the physician's role as "disqualifier" versus "educator/informer."
In short, the guidelines are too strict, said Dr. Ackerman. Philosophy and art trump science and evidence as the underpinnings of the ESC and Bethesda guidelines. He added, "Athletes and their families have the right to know the evidence or lack of evidence that go into their disqualification. Athletes and their families are fully capable to choose to disqualify themselves."
Among those who choose to remain an LQTS athlete, the LQTS-triggered event rate has been "extremely low." The guidelines are not only too strict, he said, but they advocate genetic discrimination.
Dr. Ackerman and colleagues are developing an alternative 'middle ground' to the 'just say no' approach to sports participation. He discusses this "more reasonable" approach in his ACCEL interview.
1. Maron BJ, Mitchell JH. J Am Coll Cardiol. 1994;24:845–99.
2. Pelliccia A, Fagard R, Bjørnstad HH, et al. Eur Heart J. 2005;26:1422-45.
3. Maron BJ, Zipes DP. J Am Coll Cardiol. 2005;45:1312-75.
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