Introduction

Clinicians who practice sports cardiology have an obligation to care for both the medical and psychological well-being of their athletes. Many practitioners fail to recognize the impact of routine screening, advanced testing, or surgical procedures on the athlete psyche.

Sports cardiology literature has often focused on learning the medical benefits or consequences of screening. However, very few studies have examined the psychological impact or perspectives of the athletes who undergo these protocols, even though they are most affected by these investigations.^1-4 The psychological impact of screening in athletes has been recognized as a knowledge gap in recently released guidelines produced by a working group of the National Heart, Lung, and Blood Institute.⁵

Screening may be perceived differently based on a number of factors. For example, the impact may vary by individual, diagnostic results, or level of play. It is imperative to recognize that psychological outcomes can include both positive and negative reactions. This article examines the psychological impact of cardiac screening in athletes, risk factors associated with adverse emotional outcomes, and potential ways that the treating physician can assist players diagnosed with cardiac disease who must cope and may require emotional support.

Perception of Screening Results

Many athletes may not truly understand the medical reasons for the pre-participation exam (PPE) and view it as an obstacle or formality prior to the start of the season. In fact, some athletes do not even realize that the traditional PPE (history and physical) screens for cardiac disease.

Initial data suggest that high school athletes who receive a PPE (with or without an electrocardiogram (ECG)) do not report undue distress toward results that are normal or false positive.² One reason may be that athletes consider themselves to be among the healthiest segment of society, and many simply do not believe that they are at risk for disease. Advanced screening modalities, such as an ECG, tend to make the athlete more aware that a medical team is performing cardiovascular (CV) screening. Interestingly, athletes who receive advanced screening protocols beyond the traditional history and physical report a positive impact, such as feeling safer during training or competition, more satisfaction, and even describe potentially long-term psychological benefits.^1,2

Unfortunately, adverse emotional outcomes often occur in athletes diagnosed with actual cardiac disease. Their sentiments are often minimized until a player is told that he/she cannot play sports. At this point, the challenge to the athlete identity creates vulnerability and the realization that their condition may be serious. It is vital that treating physicians understand the potential short and long-term psychological consequences that occur in athletes diagnosed with potentially lethal cardiac disease.

Stages of Psychological Impact for Athletes Diagnosed with Cardiovascular Disease (CVD)

After being diagnosed with a CV disorder, young athletes typically follow four discrete stages:

1. Immediate Reactions
2. Grief and Coping
3. Adaptation
4. Acceptance

Stage 1: Immediate Reactions
Athletes are distinctively healthy and often have no other chronic diseases. As a result, the diagnosis of a serious CVD leads to feelings of denial, shock, anxiety, and confusion.³ Physicians must recognize that communication is key. Athletes may not initially comprehend the nature of the disease, treatment options, or large quantities of complicated information. Instead, it may be more appropriate to present information in a step-wise and gradual approach, involve parents in the discussion during the initial and follow-up visits, and allow ample time for questions.

Stage 2: Grief and Coping
Athletes often cope with stress through exercise. Unfortunately, many of the athletes diagnosed with cardiac disease are restricted in their ability to exercise, or even disqualified from sporting activities. This can place a tremendous burden on the athlete. Athletes may receive emotional support from friends, family, and team members. However, emotional support and disease education from physicians post-diagnosis has been shown to carry incredible weight in the eyes of the athlete.³ This includes spending time to describe procedures, treatments, or surgeries, and even involves explaining simple medical procedures such as intravenous line insertion or placement in a cardiac magnetic resonance imaging (MRI) machine, as this is likely the first time that the athlete has encountered the medical system.

Stage 3: Adaptation
As athletes begin to adapt to their disease, they develop new routines and perspectives. This includes monitoring their heart rate during physical activity, taking daily medication for their disease, or getting used to their implantable cardioverter defibrillator (ICD). Athletes who are disqualified from athletic competition often look for ways to fill the void of athletics through other activities on the team, at school, or their community. Some even consider spreading awareness about screening or providing mentorship for other young athletes who are newly diagnosed with a CV disorder.

Stage 4: Acceptance
The progression to the last stage of acceptance is often coupled to several elements such as disease type, nature of treatment options, and whether the athlete could return to sport. Athletes with cardiomyopathy or channelopathy describe long-term emotional considerations and challenges, whereas athletes with Wolff-Parkinson-White or Atrial Septal Defects can typically undergo corrective procedures that may allow for continued athletic participation. Athletes who fully return to sport generally describe no long-term impact on daily life. Those who are disqualified from athletic competition tend to have better outcomes if they can develop a positive outlook on daily life or their condition. For example, athletes may feel gratitude that their condition was found prior to undergoing a serious cardiac event. Complete removal from athletic competition is associated with adverse consequences, inhibited coping mechanisms, and feelings of isolation. These athletes need the most support and would benefit from finding ways to continue at least some level of athletic activity for both personal and mental health.

Experiences Based on Level of Play

Although all athletes diagnosed with cardiac disease may be at risk for adverse psychological outcomes, collegiate and elite athletes may carry an elevated risk. These athletes often specialize in a single sport, which demands time, energy, and dedication to play at a higher level. The threat of removal from athletic competition places their identity in jeopardy. High school athletes may describe similar feelings; however, many perform multiple sports and those disqualified from a single sport may still have the option to choose to participate in lower intensity athletics or other recreational activities. Ultimately, this may curb undesirable emotional reactions.

Temporary Restriction vs. Permanent Disqualification

Athletes react similarly during the period immediately following the diagnosis of a serious or potentially lethal cardiac condition. Again, the progression toward acceptance may be coupled to several elements such as disease type, nature of treatment options, and whether an athlete can return to sport. For example, athletes with cardiomyopathy and channelopathy who are permanently disqualified from competition describe long-term emotional challenges compared to athletes who can undergo simple corrective procedures (e.g. cardiac ablation or patch closure) with eventual full return to sport. The latter group often depicts no impact on daily life following definitive treatment and resumption of normal daily activities.

Many disqualified athletes do not feel "normal" compared to their peers. Different factors may contribute to this belief, including activity restriction and disruption to daily routines. A consistent concern in the period immediately following diagnosis is a lack of acceptance for the decision by the healthcare team to be medically disqualified. They may wonder about alternative management or therapies to return them to sport. A recent study of 372 athletes with ICDs, followed for a median of 31 months, found no occurrences of death, resuscitated arrests, or shock-related injury.⁶ Life with an ICD brings its own unique challenges and psychological implications. Perhaps, however, these data suggest that physicians and athletes can consider more informed decision-making regarding implantation and/or sports participation with an ICD.⁶ Similarly, a recent study demonstrated a low rate of cardiac events for athletes with Long QT syndrome who were medically managed.⁷ Studies such as these provide some evidence that detection of CVD may not necessarily equal disqualification. If this is the case, it could contribute to minimizing the psychological burden of young athletes who are diagnosed with a CV disorder.

Should Disqualified Athletes Continue to be a Part of the Team?

Disqualified athletes may have mixed emotions regarding continued participation in team activities in a non-competitive role (e.g. film or equipment manager, coach, etc.). An athlete's social network may heavily revolve around team members, schedule of events, training, and games. Complete removal from these activities can have significant adverse consequences, inhibit coping mechanisms, and contribute to feelings of emptiness. On the other hand, constant reminders of the inability to compete may be depressing and can sometimes be a barrier in the transition from athlete to a different personal identity. Recommendation to continue team participation should certainly be explored in conjunction with the athlete's preferences, but the decision must be individualized on a case-by-case basis.

Long-term Implications

The concerns of young athletes in high school and college may gradually change as they get older, especially for individuals who cannot receive definitive treatment and may face decades of life with the disease. For example, scars from surgery or ICD implantation may be considered as signs of toughness in some scenarios, but could also be a source of insecurity. Athletes with genetically inheritable conditions may have additional concerns when first discussing the disease with a significant other, or when contemplating a future family. Emotional support should be tailored appropriately, evolve based on athlete concerns, and be re-visited periodically, especially during periods of life transitions.

Caring for the Athlete Diagnosed with Cardiac Disease

It is crucial that physicians who perform screening in athletes learn effective methods of how to deliver the news of cardiac diagnoses. Ideally, the conversation occurs face-to-face with the athlete and possibly even key support individuals (e.g. parents, athletic trainers). Healthcare professionals should have adequate knowledge about the disease state and describe it on a patient-specific level with caution to avoid an overload of information, as it may be difficult for the athlete to process completely. Handouts and diagrams can be used to facilitate conversation, and close follow-up is preferred to continue gradually discussing the disease process, treatment options, potential return to sport, and an assessment of mental well-being. Being well-informed of the medical condition is necessary as this understanding can enhance psychological outcomes and adherence. Athletes who appear to have adverse emotional reactions should be referred to someone skilled in behavioral and mental health who, in conjunction with the team physician, can provide further emotional support.

Conclusion

Physicians who screen athletes for cardiac disorders should learn effective communication strategies and highly consider developing support mechanisms for athletes diagnosed with CVD. Ideally, this would involve a multi-disciplinary team that could be used immediately after a diagnosis is made. Sports medicine, primary care, and cardiology physicians are in unique positions to address potential psychological morbidity. As a result, they should develop an approach to CV testing that demonstrates awareness and sensitivity to these issues. Athletes at high-risk may be referred for counseling provided by an expert in mental health. Further research is needed to understand the psychological benefits and/or consequences that result from CV screening and diagnosis in athletes, and also to develop tools to better assist physicians in determining who is at high-risk for adverse emotional outcomes.

References

1. Asif IM, Johnson S, Schmieg J, et al. The psychological impact of cardiovascular screening: the athlete's perspective. Br J Sports Med 2014;48:1162-6.
2. Asif IM, Price D, Harmon KG, Salerno JC, Rao AL, Drezner JA. The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender. Clin J Sport Med 2015;25:464-71.
3. Asif IM, Price D, Fisher LA, et al. Stages of psychological impact after diagnosis with serious or potentially lethal cardiac disease in young competitive athletes: a new model. J Electrocardiol 2015;48:298-310.
4. Solberg EE BT, Andersen TE, Ekeberg Ø.. Cardiovascular pre-participation screening does not distress professional football players. Eur J Prev Cardiol 2012;19:571-7.
5. Kaltman JR, Thompson PD, Lantos J, et al. Screening for sudden cardiac death in the young: report from a national heart, lung, and blood institute working group. Circulation 2011;12317:1911-8.
6. Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation 2013;12720:2021-30.
7. Johnson JN, Ackerman MJ. Return to play? Athletes with congenital long QT syndrome. Br J Sports Med 2013;471:28-33.

Keywords: Anxiety, Athletes, Cardiomyopathies, Channelopathies, Chronic Disease, Cicatrix, Counseling, Defibrillators, Implantable, Electrocardiography, Follow-Up Studies, Grief, Heart Rate, Heart Septal Defects, Atrial, Long QT Syndrome, Magnetic Resonance Imaging, Mental Health, Mentors, Motor Activity, Patient Care Team, Personal Satisfaction, Primary Health Care, Recreation, Risk Factors, Social Support, Sports, Sports Medicine

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