Any discussion regarding athletes and implantable cardioverter defibrillators (ICDs) could use some historical context. Loyola Marymount University forward Hank Gathers collapsed on March 4, 1990, during a game and died later in the day after being hospitalized. The 23-year-old National Basketball Association (NBA) prospect had exercise-induced ventricular tachycardia and had been prescribed a beta-blocker (propranolol) after experiencing syncope during a free throw just 3 months earlier. However, the athlete felt the drug adversely affected his play; so, according to subsequent news reports, he cut back his dosage and, some suspect, was not taking any dosage on game days.

The Gathers court collapse was shown—over and over—on television, leading to what David S. Cannom, MD, of the University of California Los Angeles (UCLA) School of Medicine, described as the "1990 paradigm": high-profile colleges made sports participation decisions to protect their sports programs and avoid 'another Gathers' on TV. Thus, when a 20-year-old center on the Pepperdine University basketball team subsequently fainted on the court, with no premonitory symptoms, hypertrophic cardiomyopathy was diagnosed and an ICD implanted – he was turned down for athletic scholarships at Pepperdine and UCLA despite waivers signed by the patient and his family as well as supportive letters from electrophysiologists.

Dr. Cannom said the reason given for rejection was the restrictive Bethesda Guidelines for Athletes with Cardiovascular Abnormalities and the legal concerns of the universities.¹ The athlete ultimately played division I basketball at Texas Tech for 2 years without complication and now is a basketball coach at UC Riverside.

Recommendations (in Lieu of Data)

The 36th Bethesda Conference Report was based on the clinical experience of experts; according to Dr. Cannom, there was scant literature and no randomized clinical trials to support the recommendations made back in 2005, yet the recommendations had the same authority as traditional guidelines. Therefore, the words carried weight when the document stated: "Although differences of opinion exist and little direct evidence is available, the panel asserts that the presence of an ICD (whether for primary or secondary prevention of sudden death) should disqualify athletes from most competitive sports (with the exception of low-intensity, class IA), including those that potentially involve bodily trauma."²

Dr. Cannom is certainly not the first to criticize the ACC recommendations for competitive athletes with heart abnormalities as overly restrictive (see the July 2013 and February 2014 issues of ACCEL); the co-chairs themselves—Barry J. Maron, MD, and Douglas P. Zipes, MD—acknowledged in the 2005 document that the 36th Bethesda Conference report was presented in the context of "measured and prudent recommendations – intended neither to be overly permissive nor restrictive, nor regarded as an absolutely rigid dictum." They wrote: "Indeed, the managing physician with particular knowledge regarding a given athlete's cardiovascular abnormality, psychological response to competition, and other medically relevant factors may choose to adopt somewhat different recommendations in selected individuals."

Concerns—But Now Data

There were a number of postulated risks of sports in these patients:

• death
• inability of the ICD to defibrillate due to the influence of the effects of vigorous exercise
• injury due to syncopal arrhythmia or shock
• damage to the ICD or lead system

Now data are becoming available and, as noted above in the discussion of the prospective multicenter registry data of Lampert et al., many athletes with an ICD engage in sports without physical harm.³ By the way, while not mentioned above, Dr. Lampert and colleagues reported a lead survival free of definite malfunction (from implantation date) of 97% at 5 years and 90% at 10 years. Adding in definite plus 'possible' malfunctions, the survival rate free of lead malfunction was 93% at 5 years and 84% at 10 years. So, despite active sports training and participation, those percentages are similar to previously described survival rates of 85% to 98% free of lead problems at 5 years in more typical ICD populations.

In his protagonist view, Dr. Cannom reviewed the Lampert data noting that while ICD shocks occurred in the registry participants, there were no tachyarrhythmia deaths, resuscitated cardiac arrests, or injuries related to sports participation. Echoing the investigators themselves, Dr. Cannom said "Athletic participation for these patients is an issue of quality of life: shock can decrease quality of life, but so can sports restriction."

Clinical management, he said, includes device programming to prevent shocks and use of remote monitoring to evaluate lead function.

"This study," he said, "gives support to allowing some athletes with ICDs to participate in noncontact sports." Put another way, the study results epitomize "patient-centered care," defined as care "respectful of and responsive to individual patient preferences, needs, and values."

(Editor's note: Hank Gathers was not the first young athlete to make headlines he never wanted, nor will he be the last. This summer, college star Isaiah Austin was considered a first-round NBA prospect when he learned he has Marfan syndrome. The Baylor power forward/center has ended his basketball career, although he already has offers for a coaching career once he graduates from Baylor.)

References

1. Maron BJ, Zipes DP, Graham TP, et al. J Am Coll Cardiol. 2005;45:1312-77.
2. Maron BJ, Zipes DP. J Am Coll Cardiol. 2005;45:1318-21.
3. Lampert R, Olshansky B, Heidbuchel H, et al. Circulation. 2013;127:2021-30.
4. Kramer DB, Maisel WH. Guidelines for managing pacemaker and implantable defibrillator advisories. In: Ellenbogen KA, ed. Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy. Philadelphia, PA: Elsevier Saunders; 2011.

Keywords: Athletes, Heart Defects, Congenital, Cardiovascular Abnormalities, Propranolol, Cardiomyopathy, Hypertrophic, Electric Countershock, Sports, Syncope, Los Angeles, Patient-Centered Care, Fellowships and Scholarships, Television, Tachycardia, Ventricular, Quality of Life, Survival Rate, Basketball, Patient Preference, Death, Sudden, Cardiac, Defibrillators, Implantable

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