Return-to-Play for Elite Athletes With Genetic Heart Diseases

Quick Takes

  • In a retrospective, observational, multicenter study of elite (NCAA Division I or professional) athletes diagnosed with a SCD-predisposing-genetic heart disease who were seen at a tertiary sports cardiology expertise center, a majority of athletes (55 of 76, 72%) opted for unrestricted return to play after comprehensive clinical evaluation and shared decision making.
  • With a mean follow-up of 7 ± 6 years, only one exercise related (1.3%) and two nonexercise related breakthrough cardiac events (2.6%) occurred, with no fatalities during follow-up.

Study Questions:

What are the clinical outcomes among National Collegiate Athletic Association (NCAA) Division I collegiate athletes and professional athletes diagnosed with a genetic heart disease (GHD) predisposing to sudden cardiac death (SCD) who have returned to play (RTP)?


Clinical data were extracted from medical records at four tertiary sports cardiology expertise centers to identify all elite (NCAA Division I, Olympic, or professional) athletes diagnosed with a SCD-predisposing-GHD (arrhythmogenic right ventricular cardiomyopathy [ARVC], catecholamine polymorphic ventricular tachycardia [VT], dilated cardiomyopathy [DCM], hypertrophic cardiomyopathy [HCM], idiopathic ventricular fibrillation [VF], long QT syndrome [LQTS], or left ventricular noncompaction associated cardiomyopathy). The RTP process at each institution utilized a process of shared decision making (SDM) albeit without standardized methodology. The primary clinical outcome was breakthrough cardiac events (BCEs) defined as arrhythmic syncope or seizures, symptomatic nonsustained VT, appropriate VT and/or VF-terminating therapy from an implantable cardioverter-defibrillator (ICD), sudden cardiac arrest with external defibrillator rescue, sustained VT, or SCD after diagnosis and initiation of treatment. BCEs were further categorized in terms of occurrence before RTP, after RTP at an elite level, or after the conclusion of the elite athlete career; and patient activity (athletic or nonathletic) at the time of BCE.


Seventy-six elite (66% Division I, 34% professional) athletes (age 19.9 ± 5 years, 28% female) diagnosed with GHD (53% HCM, 26% LQTS, 7% DCM, 5% ARVC, 9% other) were identified. Most athletes were asymptomatic (48 of 76, 63%) prior to diagnosis and had GHD detected during routine pre-participation cardiovascular screening. Most athletes (55 of 76, 72%) initially were disqualified from sport but subsequently opted for unrestricted RTP after comprehensive clinical evaluation and SDM. With a mean follow-up of 7 ± 6 years, only one exercise related (1.3% [syncope in a patient with HCM]) and two nonexercise related BCEs (2.6% [ICD shock in a patient with HCM, syncope in a patient with LQTS]) occurred; with no fatalities during follow-up.


After careful evaluation, risk stratification, and tailoring of GHD therapy among athletes with a known SCD-predisposing-GHD who are competing at an elite level, RTP following SDM appears to be associated with a low incidence of nonfatal cardiac events.


People diagnosed with a SCD-predisposing-GHD historically have been unconditionally restricted from participation in competitive sports, but emerging data suggest that the risks associated with RTP might not be prohibitive. This retrospective, observational, multicenter study found that a process of SDM led to RTP among a majority of but not all athletes who had been previously disqualified from sports participation; and that there were low rates of exertional and nonexertional BCEs among those who returned to elite level athletic participation, and no fatal events. Although the study is limited by its retrospective design, a potentially biased population that predominantly self-referred to a tertiary care sports center, and no standardized methods for SDM; it reinforces the importance of the sports cardiologist/genetic cardiologist as a member of the athletic medical team, and it provides support for a strategy of SDM following consultation and disease management among athletes who are at higher risk for SCD during athletic participation.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Sports and Exercise Cardiology, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Sports and Exercise and Congenital Heart Disease and Pediatric Cardiology

Keywords: Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Cardiomyopathy, Dilated, Cardiomyopathy, Hypertrophic, Catecholamines, Death, Sudden, Death, Sudden, Cardiac, Decision Making, Shared, Defibrillators, Implantable, Heart Failure, Long QT Syndrome, Return to Sport, Risk, Secondary Prevention, Sports, Syncope, Tachycardia, Ventricular, Ventricular Fibrillation

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