My PracticeUpdate Article of the Year 2023

This was published in PracticUpdate Commentaries Cardiology Expert Opinion / Commentary · December 11, 2023

I selected Martinez and colleagues’ article on athletes with potentially dangerous cardiac abnormalities returning to competition1 as my top story of the year because it both answers and raises questions on this topic.

The article reports the clinical outcome of 76 elite athletes with potentially dangerous cardiac conditions who were evaluated by experts at four institutions. Most of the athletes (n = 69, or 91%) elected to return to play after a shared decision with the expert clinician, 3 athletes (4%) decided not to participate, and 4 (5%) were not allowed by their physician or organization to participate. The athletes were considered “elite” because they played either in NCAA Division I or professional sports. The athletes’ average age was 19.9 years and most (72%) were men. Their conditions included hypertrophic cardiomyopathy (HCM) (53%), long QT syndrome (26%), arrhythmogenic cardiomyopathy (5%), idiopathic ventricular fibrillation (3%), dilated cardiomyopathy (7%), and other potentially fatal diseases. The athletes were treated with a variety of interventions, including medications (45%), ICDs (32%), and left cardiac sympathetic denervation (8%). More than half (53%) were diagnosed during the pre-participation screening whereas only 24% presented with symptoms. The remaining 23% were diagnosed either by family history or after an unrelated event.

There were only three cardiovascular events, none fatal, over 7.6 years of follow-up. These included an activity-related ICD shock in a man with HCM, an activity-related seizure in a man with long QT syndrome, and a resting syncopal event in another man with HCM. All three events occurred among the 18 athletes who were symptomatic before diagnosis, leading to an event rate of 16%.

So, what are the answers? Asymptomatic athletes with potentially dangerous cardiac conditions can return to competition after expert guidance, with low risk of a cardiac event. What are the questions? Does this conclusion apply to symptomatic athletes? Does pre-participation screening of asymptomatic athletes save lives or simply identify low-risk athletes with a cardiac condition?

I have more than 40 years of interest in the cardiac complications of exercise,2 and I have wondered if we should downplay pre-participation screening and, instead, concentrate on evaluating symptomatic athletes, teaching CPR to athletes and coaches, and requiring defibrillators and emergency action plans to deal with emergencies both on the field and in the stands.3

We need more and larger studies like this report by Martinez and colleagues to ultimately answer these questions.

1. Martinez KA, Bos JM, Baggish AL, et al. Return-to-Play for Elite Athletes With Genetic Heart Diseases Predisposing to Sudden Cardiac Death. J Am Coll Cardiol. 2023;82(8):661–670.
2. Thompson PD, Stern MP, Williams P, et al. Death During Jogging or Running: A Study of 18 Cases. JAMA. 1979;242(12):1265–1267.
3. Thompson PD, Baggish AL, Blaha MJ, et al. Increasing the Availability of Automated External Defibrillators at Sporting Events: A Call to Action from the American College of Sports Medicine. Curr Sports Med Rep. 2021;20(8):418–419.