AHA/ACC Scientific Statement: Eligibility and Disqualification Criteria for Athletes With Cardiovascular Abnormalities

Maron BJ, Zipes DP, Kovacs RJ.
Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: A Scientific Statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;Nov 2:[Epub ahead of print].

This is an update to the Bethesda #36 report (2005) addressing eligibility and disqualification criteria for competitive athletes with cardiovascular conditions. As with previous reports, its emphasis is toward student athletes of high school and college age (12–25 years). There is a preamble and 15 Task Forces, each with unique titles and authors. The following is a list of the 15 Task Forces, and a few points to remember for each:

  1. Task Force 1: Classification of Sport: Dynamic, Static, and Impact. All sports are classified in terms of their dynamic and static natures, impact, and respective intensities (low, medium, high).
  2. Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes. Data from the Veneto region of Italy that support the utility of electrocardiography (ECG) screening among all competitive athletes have not been reproduced in other settings. The current recommendations stress the utility of a standardized history and physical examination for purposes of screening competitive athletes. ECG screening in small cohorts of young people may be considered in addition to a comprehensive history and physical examination, but should not necessarily be limited to athletes and should be done only with close physician supervision and sufficient quality control.
  3. Task Force 3: Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis. Specific recommendations are made, including participation of hypertrophic cardiomyopathy (HCM) genotype-positive athletes without left ventricular hypertrophy, counseling against the placement of prophylactic implantable cardioverter-defibrillators (ICDs) in athletes with HCM for the sole purpose of athletic participation, and assuring that athletes with probable or definitive myocarditis defer returning to athletic participation until evidence that active inflammation has resolved.
  4. Task Force 4: Congenital Heart Disease (CHD). Recommendations are based on categories of CHD including:
    • Simple shunts (atrial septal defect, ventricular septal defect, patent ductus arteriosus)
    • Pulmonic and aortic stenosis, and aortic coarctation
    • Increased pulmonary vascular resistance in CHD
    • Cyanotic CHD, including tetralogy of Fallot
    • Transposition of the great arteries (D-loop, L-loop)
    • Ebstein’s anomaly
    • Coronary artery anomalies
  5. Task Force 5: Valvular Heart Disease. Recommendations are based on categories of valve disease including:
    • Aortic stenosis, aortic regurgitation, bicuspid aortic valve
    • Mitral stenosis, mitral regurgitation
    • Athletes having undergone surgical intervention for valve disease
  6. Task Force 6: Hypertension. Recommendations include careful assessment of blood pressure prior to beginning athletic training (Class I); allowable athletic participation for athletes with stage 1 hypertension in the absence of target organ damage (Class I); and restriction from participation, particularly from high static sports (e.g., weight lifting, boxing, wrestling) of athletes with stage 2 hypertension (blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥100 mm Hg) even in the absence of target organ damage.
  7. Task Force 7: Aortic Diseases, Including Marfan Syndrome. Recommendations include indexing the observed aorta diameter to an expected aorta size (Devereux RB, et al. Am J Cardiol 2012;110:1189-94), and separately addressing athletes with Marfan syndrome, bicuspid aortopathy, and family history of aortic disease.
  8. Task Force 8: Coronary Artery Disease. Recommendations include performance of maximal exercise testing in competitive athletes with known atherosclerotic coronary artery disease for assessment of inducible ischemia and exercise-induced electrical instability (Class I), and assessment of left ventricular systolic function among athletes with known coronary artery disease (Class I).
  9. Task Force 9: Arrhythmias and Conduction Defects. Recommendations are based on the following categories:
    • Sinus bradycardia
    • First- and second-degree heart block; right bundle branch block, left bundle branch block, and complete heart block
    • Supraventricular tachycardia, atrial fibrillation and flutter, atrioventricular nodal re-entrant tachycardia
    • Premature ventricular contractions, nonsustained ventricular tachycardia (VT), sustained monomorphic and sustained polymorphic VT
    • Athletes with an ICD
  10. Task Force 10: The Cardiac Channelopathies. Recommendations include evaluation by a heart rhythm specialist or genetic cardiologist with experience and expertise in channelopathies (Class I); and restriction from all competitive sports of any symptomatic competitive athlete with suspected or diagnosed cardiac channelopathy until a comprehensive evaluation has been completed, a treatment program has been implemented, and the athlete is asymptomatic on treatment for 3 months (Class I).
  11. Task Force 11: Drugs and Performance Enhancing Substances. As a condition of participation in athletic activities, performance-enhancing drugs and supplements should be prohibited by schools, universities, and other sponsoring/participating organizations.
  12. Task Force 12: Emergency Action Plans, Resuscitation, CPR, and AEDs. Schools and organizations hosting athletic events should have an emergency action plan (Class I); coaches and athletic trainers should be trained to implement timely cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) placement (Class I); and an AED should be available to a cardiac arrest victim within 5 minutes in all settings, including competition, training, and practice (Class I).
  13. Task Force 13: Commotio Cordis. Defined as sudden cardiac death triggered by a relatively innocent blow to the precordium, commotion cordis is a rare event; focus should be on recognition and timely intervention, including CPR and defibrillation.
  14. Task Force 14: Sickle Cell Trait. Recognized as a nontraumatic risk of sports participation, recognition of sickle cell trait is not a justification for disqualification from athletic participation (Class I). Preventative strategies (adequate rest, hydration) should be performed to minimize the likelihood of a cardiac event in an athlete with sickle cell trait (Class I).
  15. Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations. A physician’s general legal duty is to conform to accepted, customary, or reasonable medical practice in providing medical recommendations for sports participation that are consistent with an athlete’s short- and long-term best medical interests; a physician’s best medical judgment should not be compromised by an athlete’s desire to participate and in so doing assume medically unreasonable risk, or by the team’s desire for the athlete’s talents.

Keywords: Acute Coronary Syndrome, Aortic Coarctation, Aortic Valve Insufficiency, Aortic Valve Stenosis, Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Atrial Fibrillation, Blood Pressure, Bradycardia, Bundle-Branch Block, Cardiomyopathy, Hypertrophic, Cardiopulmonary Resuscitation, Channelopathies, Commotio Cordis, Coronary Artery Disease, Death, Sudden, Cardiac, Defibrillators, Implantable, Ductus Arteriosus, Patent, Ebstein Anomaly, Electrocardiography, Heart Defects, Congenital, Heart Septal Defects, Atrial, Heart Septal Defects, Ventricular, Heart Valve Diseases, Hypertension, Hypertrophy, Left Ventricular, Marfan Syndrome, Mitral Valve Insufficiency, Mitral Valve Stenosis, Myocarditis, Performance-Enhancing Substances, Sickle Cell Trait, Tachycardia, Ventricular, Tetralogy of Fallot, Transposition of Great Vessels, Ventricular Premature Complexes

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