Editor's Note: Commentary based on Dean PN, Gillespie CW, Greene E, et al. Sports participation and quality of life in adolescents and young adults with congenital heart disease (SQUAD study). J Am Coll Cardiol 2014;63:(12_s).

For physicians, the question of whether or not a patient with congenital heart disease (CHD) should participate in physical activity or competitive sports can be difficult. On the one hand, we want these patients to be involved in activities with friends instead of sitting in front of a television or computer screen all day. On the other hand, some patients with CHD continue to have significant residual cardiac disease through their adolescence, and there is fear that they may have an adverse event on the athletic field.

While the SQUAD study¹ did not completely resolve this dilemma, it provides data that can help physicians when they are struggling to determine whether to allow sports participation. The SQUAD study was a cross-sectional study that looked at physical activity, type and intensity of sports participation, reasons for sports restrictions, and quality of life in a cohort of 177 adolescents and young adults with a variety of types of CHD.

The study finds that patients with CHD are participating in competitive sports, perhaps to a greater degree than previously thought. More than half of the patients in the cohort (52%) participate in some form of competitive sports, and some do at fairly high levels (28 patients on varsity-level high school teams and six participate on intercollegiate teams). Many patients are also participating in sports that would not be allowed by the 36th Bethesda Conference guidelines.² Sixty-five percent (15/23) of the patients with severe CHD who are participating in a competitive sport do so against the Bethesda guidelines, and 100% (7/7) of the patients with a single ventricle who participate in a competitive sport do so against the Bethesda guidelines. These patients are not just participating in golf or billiards (class IA sports³ with low static and dynamic components), but they are participating in sports at the medium to high levels of static and dynamic components.

The study also found that patients in this cohort who participate in more frequent physical activity and competitive sports have higher quality of life scores, lower body mass indexes (BMIs), and perform better on exercise tests. These findings remained significant after controlling for age, sex, CHD severity, residual cardiac disease, and comorbid conditions. Improved survival for patients with CHD has shifted focus to improving quality of life and reducing adult cardiovascular risk factors. Sports participation may be an important component in these areas.

Restricting patients with CHD may also not be a completely benign decision and may have deleterious effects on the patient's quality of life score. Patients who reported any type of sports restriction had significantly lower physical quality of life scores (p = 0.03), and there was a trend towards lower total quality of life scores (p = 0.16).

Lastly, not only are patients participating against 36th Bethesda Conference guidelines, but physicians are not uniformly following these guidelines. In this cohort, 21% of the patient's cardiologists documented recommendations that were more permissive than expert guidelines.

This study does not comment on the safety of sports participation, and there are certainly patients who have a clear reason and need for sports restrictions (severe aortic stenosis, exercise induced arrhythmias or boxing for a patient on warfarin to name a few). However, the study does show that sports participation, even at high levels, is prevalent and has beneficial effects on quality of life, BMI, and exercise capacity. Two recent consensus statements from the U.S. and Europe^4,5 have advocated promotion of physical activity in patients with CHD. This study provides some data supporting these consensus statements in encouraging a shift from a restrictive toward a more permissive approach to physical activity and sports participation in patients with CHD.

References

1. Dean PN, Gillespie CW, Greene E, et al. Sports participation and quality of life in adolescents and young adults with congenital heart disease (SQUAD study). J Am Coll Cardiol 2014;63:(12_s).
2. Graham TP, Driscoll DJ, Gersony WM, et al. Task Force 2: congenital heart disease. J Am Coll Cardiol 2005;45:1326-33.
3. Mitchell JH, Haskell W, Snell P, Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol 2005;45:1364-7.
4. Longmuir PE, Brothers JA, de Ferranti SD, et al. Promotion of physical activity for children and adults with congenital heart disease: a scientific statement from the American Heart Association. Circulation 2013;127:2147-59.
5. Takken T, Giardini A, Reybrouck T et al. Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology. Eur J Cardiovasc Prev Rehabil 2012;19:1034-65.

Keywords: Adolescent, Adult, Aortic Valve Stenosis, Arrhythmias, Cardiac, Body Mass Index, Boxing, Cardiovascular Diseases, Consensus, Cross-Sectional Studies, Exercise, Exercise Test, Fear, Friends, Golf, Heart Diseases, Humans, Prevalence, Quality of Life, Risk Factors, Sports, Television, United States, Warfarin

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