The Heart Rhythm Society released new expert consensus recommendations on evaluating, treating, and managing arrhythmias in athletes.

The comprehensive document, published in Heart Rhythm, provides guidance on a wide range of arrhythmia-related issues specific to athletes, emphasizing shared decision-making and facilitating return to play when appropriate.

Key Recommendations:

• For many arrhythmogenic conditions, current data did not confirm increased risk with sports participation for appropriately risk-stratified and treated athletes. The approach to return to play should involve individualized shared decision-making.
• The goal should be facilitating return to sport when desired, through appropriate risk assessment and management. Restriction from sport is not benign.
• Emergency action plans including early defibrillation are critical for survival of sudden cardiac arrest (SCA) in athletes.
• Disease-specific risk assessment and guideline-based treatment are needed before return to play.
• For complex arrhythmias, appropriate strategies for sudden death prevention and arrhythmia suppression are needed before return to play, including confirmation of suppression during exercise.
• Treatment decisions should consider impact on athletic performance and training.
• Exercise stress testing to evaluate arrhythmias should mimic the athlete's sport where possible.
• Endurance exercise may contribute to conditions like atrial fibrillation and arrhythmogenic right ventricular cardiomyopathy; risks and benefits should be carefully weighed.
• Choice of pacemaker/defibrillator and programming should consider the athlete's sport to minimize risk of system damage.

The guidelines emphasized that for many arrhythmogenic diseases, data in athletes have not confirmed increased risk with sports participation when appropriately risk-stratified and treated. Therefore, return to play decisions should involve shared decision-making between the athlete, family, and medical team.

The writing committee included international experts in sports cardiology, electrophysiology, and genetics. The document was developed in collaboration with multiple professional societies and underwent extensive peer review.

Comprehensive emergency action plans with early defibrillation capability were deemed critical for survival of SCA in athletes. The document provided recommendations on implementing effective emergency response protocols. Data showed that survival rates of 85% have been reported for sports-related SCA in high school athletes when witnessed and an AED was used.

For athletes with complex arrhythmias, appropriate sudden death prevention strategies and arrhythmia suppression were needed prior to return to play. This included confirmation of arrhythmia suppression during maximal exercise testing that mimics the athlete's sport.

The guidelines noted endurance exercise may contribute to certain arrhythmogenic conditions like atrial fibrillation and arrhythmogenic right ventricular cardiomyopathy. The risks and benefits of continued participation in endurance sports should be carefully weighed for athletes with these conditions.

Recommendations were provided on evaluating specific arrhythmias in athletes, including premature ventricular contractions, supraventricular tachycardia, and atrial fibrillation. The document emphasized distinguishing benign athlete's heart changes from pathological findings.

For athletes requiring pacemakers or implantable cardioverter-defibrillators (ICDs), device selection and programming should take into account the type of sport to minimize risk of system damage. Recommendations were provided on appropriate waiting periods before return to play after device implantation.

The guidelines addressed the management of inherited arrhythmia syndromes and cardiomyopathies in athletes. For many of these conditions, the document noted that data do not show increased risk with sports participation when athletes are appropriately evaluated and treated. Recommendations emphasized shared decision-making regarding return to play.

Specific guidance was provided on evaluation and management of Wolff-Parkinson-White syndrome in athletes. The document noted there is a lack of conclusive evidence of increased risk during sports participation.

For atrial fibrillation in athletes, the guidelines discussed risk factor modification, anticoagulation, and rhythm control strategies. Catheter ablation was recommended as a reasonable first-line therapy for symptomatic atrial fibrillation in athletes.

The document provided recommendations on genetic testing and family screening for athletes diagnosed with inherited arrhythmia syndromes or cardiomyopathies. It emphasized the importance of genetic counseling and a multidisciplinary approach.

The guidelines included detailed epidemiological data on sudden cardiac arrest and death (SCA/D) in athletes. Recent systematic reviews and meta-analyses reported the rate of SCA/D in young athletes as 1.7-1.9 deaths per 100,000 person-years. The incidence was higher in males, Black athletes, and certain sports such as basketball, American football, and soccer.

Causes of SCA/D varied by age, with structural or electrical conditions being the primary causes in younger athletes and coronary artery disease in older athletes. In athletes aged < 35 years, autopsy-negative sudden unexplained death appeared to be the most frequent cause of SCA/D, followed by cardiomyopathies and coronary artery abnormalities.

The document provided specific recommendations for various inherited arrhythmia syndromes. For long QT syndrome, data from the largest cohort to date (494 athletes) showed no deaths and a low event rate of 1.16 non-lethal events per 100 athlete-years follow-up after risk assessment and personalized treatment plans.

For hypertrophic cardiomyopathy, the recent LIVE-HCM study demonstrated no increased cardiac event rate in vigorous exercisers compared with non-vigorous exercisers, supporting a shared decision-making approach to return to play.

Full disclosures can be found in the guidelines.