Can Athletes with ICDs Participate in Competitive Sports?
Can Athletes with ICDs Participate in Competitive Sports?
Abstract & Commentary
Edward P. Gerstenfeld, MD
Professor of Medicine, Chief, Cardiac Electrophysiology, University of California, San Francisco
Dr. Gerstenfeld does research for Biosense Webster, Medtronic, and Rhythmia Medical.
Source: Lampert R, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: Results of a prospective, multinational registry. Circulation 2013;127:2021-2030.
Young athletes with an inherited arrhythmia syndrome, such as long QT syndrome (LQTS) or hypertrophic cardiomyopathy (HCM), may undergo implantation of an implantable cardioverter defibrillator (ICD) if they are believed to be at high risk of sudden death. American College of Cardiology (ACC) guidelines have typically recommended that such individuals should be prohibited from vigorous sports. Yet for many young athletes, prohibition of participation in any competitive sport may be a life-altering event, followed by poor grades or depression. There is a paucity of data in athletes with ICDs and despite the ACC guidelines and physician recommendations, many athletes with ICDs continue to participate in competitive sports. Thus, the results of a prospective, multinational registry of patients with ICDs, the ICD Sports Safety Registry, is of interest. This registry enrolled and followed patients with implanted ICDs aged 10-60 years who participated in organized competitive sports having intensity more vigorous than golf or bowling. Most of the enrolled patients were already participating in competitive sports, regardless of medical advice, at the time of enrollment. Patients were asked to notify the center if they received any ICD shocks, and were questioned about the circumstances of the event. All enrollees were also called by phone every 6 months throughout the study. Stored ICD electrograms were reviewed by two cardiac electrophysiologists to confirm whether the shocks were appropriate or inappropriate. The primary endpoint was a serious adverse event occurring during or up to 2 hours after sports participation. Serious adverse events were defined as tachyarrhythmic death or externally resuscitated tachycarrhythmia, postshock pulseless electrical activity, or severe injury resulting from a shock or syncope. The lowest ICD treatment zone was set to 200 bpm. There were 328 athletes enrolled; 44 participated in sports considered "high-risk," such as basketball, soccer, or downhill skiing. The most common arrhythmia diagnoses included LQTS, HCM, and arrhythmogenic right ventricular cardiomyopathy (ARVC). Most, but not all, patients (62%) were taking beta-blockers. The most common sports that patients participated in during the registry were running, soccer, and basketball; 60 participants were on high school or college sports junior varsity/varsity teams. The median follow-up was 31 months. Two patients died during the study: a 52-year-old cyclist who died at his desk at work after receiving multiple ICD shocks and a 34-year-old volleyball and softball player with DCM who died while hospitalized for congestive heart failure. There were no occurrences of the primary endpoint during sports participation among those patients completing the study. The 95% confidence interval for events at 1 year was 0-1.2%, and at 2 years was 1-1.5%. Overall, 77 individuals (21%) received appropriate ICD shocks and 40 (11%) received inappropriate shocks. Those with ARVC or idiopathic ventricular fibrillation were more likely to receive appropriate shocks compared to those with HCM or LQTS. There were no injuries reported. There were 13 lead malfunctions during the study period. The authors concluded that participation in competitive sports by athletes with an ICD is possible without failure to terminate arrhythmias or suffering injuries.
The population of young athletes with inherited arrhythmia syndromes remains a difficult population to manage. In patients at low risk for life-threatening events, a consensus document has outlined the relative safety of various competitive sports.1 Patients are often directed from high-risk to lower-risk sports such as golf or bowling. For higher-risk patients who undergo ICD implantation, conventional wisdom has been to counsel against participation in competitive sports. Yet patients will often ask, "Now that I have this safety device which can save me in the event of a cardiac arrest, can I resume participating in competitive sports?" Most electrophysiologists have answered "no" to this question, out of fear of damage to the device or leads during sporting events, triggering of a life-threatening arrhythmic event, injury to the patient, and potential medico-legal implications. Yet, we all know some patients who continue to participate despite our recommendations. Is the accompanying article strong enough to change these recommendations and allow athletes with ICDs to participate in competitive sports? First, one must consider the type of inherited arrhythmia and the type of sporting activity. In patients with ARVC, the disease may progress more rapidly in those who exercise vigorously, and arrhythmic events are commonly triggered during extreme exercise. In the Sports Safety Registry, patients with ARVC had significantly more arrhythmic events than other inherited arrhythmias. Patients with LQTS type I have a risk of sudden death during swimming, so competitive swimming should certainly be avoided. Contact sports such as football or rugby should also clearly be avoided, as damage to the device may occur with repeated trauma. Sports with a very high aerobic exercise level, such as full court basketball or soccer, may also be more likely to trigger arrhythmic events. The authors of this article should be congratulated on contributing the first data on patients with ICDs who participate in sports. In general, I would continue to dissuade patients with inherited arrhythmias (particularly ARVC) and ICDs from participating in competitive sports. However, it does appear that some ICD patients may participate in certain competitive sports without an undue risk of injury or mortality. This should only be considered after a thorough discussion between the patient, the cardiologist, and a physician with an expertise in managing inherited arrhythmias.
1. Maron BJ, et al. Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation 2004;109:2807-2816.
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