Historically, patients with certain cardiac conditions, including cardiomyopathy and long QT syndrome (LQTS), have been advised not to participate in sports due to a presumption that vigorous exercise will increase their risk of life-threatening cardiac events.
Over the past decade, research has shown that with appropriate risk assessment and treatment, many athletes with cardiac conditions can return to playing sports without high risk.
A new study led by Rachel Lampert, MD, Robert W. Berliner Professor of Medicine (cardiovascular medicine) and director of the Yale Sports Cardiology Program, found that patients with LQTS who receive proper risk assessment and treatment in experienced centers have low cardiac event rates whether or not they exercise vigorously.
The paper, entitled “Vigorous Exercise in Patients with Congenital Long QT Syndrome (LQTS): Results of the Prospective, Observational, Multi-National, “Lifestyle and Exercise in LQTS” (LIVE-LQTS),” was recently published in Circulation.
In the following Q&A, Lampert discusses the new paper, current guidelines for college athletes, and additional research necessary to guide clinicians and patients on returning to play.
1. Tell me about the findings of your research.
In 2015, we launched LIVE-QTS, the first prospective study to investigate if vigorous exercise raises the risk of cardiac events in people with LQTS. Patients with LQTS have a rare abnormality in their heart’s electrical system.
We prospectively enrolled individuals with LQTS and/or the gene for LQTS between the ages of 8-60 from 37 enrolling sites in five countries. Participants or their parents answered surveys about their physical activity and clinical events every six months for three years.
Our study found that among these individuals with LQTS, both those who exercise vigorously and those less active, had a low—and very similar—rate of arrhythmic events, including cardiac arrest, shock from a defibrillator, or syncope due to an arrhythmia. Some individuals did experience some cardiac events during vigorous exercise, but those events were infrequent. While those exercising vigorously had rare events during exercise, sedentary and moderate exercisers had more events doing low-intensity activities, like walking the dog.
These findings are significant because they show that with appropriate risk assessments and treatment, many athletes with LQTS can return to play rather than stay on the sidelines.
2. What do guidelines tell us now about returning to play with a cardiac condition?
The guidelines have changed dramatically in the past decade or so.
When I started my career in the 1990s, guidelines said that if a person had LQTS, a defibrillator, or many other cardiac conditions, they should not play sports. Those guidelines were based on a conservative approach in the absence of evidence and a paternalistic approach to medical decision-making.
Evidence continues to emerge that vigorous exercise is not increasing the overall rate of cardiac events. We are not seeing an overall increase in the number of events in people who exercise vigorously, even though occasionally, that event did happen during exercise.
In 2015, guidance from the American Heart Association (AHA) began to describe participation in sports for patients with certain cardiac conditions as something that may be considered rather than absolutely restricted.
Earlier this year, the Heart Rhythm Society issued an expert consensus statement, which I led, to help guide decisions on sports participation for athletes with arrhythmic cardiac conditions. The statement describes sports participation as reasonable for athletes with many, although not all, cardiac conditions. These guidelines stress the importance of expert assessments, shared decision-making, appropriate treatment plans, and appropriate emergency action plans.
Our now-published study in Circulation supports the updated guidance for sports participation for athletes with Long QT.
3. Sudden cardiac arrest is one of the leading causes of death in young athletes. Students and their parents are preparing for fall sports. Is screening recommended for college athletes?
The AHA recommends that competitive athletes under 35 get a physical and personal and family history taken before playing sports. It’s especially important if people in their family have died suddenly under the age of 40, if they have any risk factors, or if they are experiencing any symptoms, like passing out during exercise, shortness of breath, or a racing heart while at rest.
Many schools further evaluate their athletes prior to sports participation with an EKG. EKG screening is known to identify more cardiac abnormalities than the history and physical alone. Right now, the National Collegiate Athletic Association (NCAA) does not mandate EKG screening for athletes, but roughly half of NCAA colleges and universities, including Yale, use them to screen more effectively.
I also partner with the foundation In a Heartbeat to work with other Connecticut colleges and universities to provide EKG screening and follow-up management as needed for their athletes.
For EKG screening to work, it's critical to have the right infrastructure in place. Schools need trained people who know what they’re looking for and what to do next if they find something. It’s not enough to spot a problem. Athletes need evidence-based information about what this means for participating in sports and if they need any specific treatment to address the problem.
4. How does vigorous exercise change the heart?
Vigorous endurance sports like running or anaerobic static sports like weightlifting can cause the heart to thicken or for heart chambers to get larger. Those are good changes that allow the heart to generate the cardiac output an athlete needs to perform in their sport, whether it’s the Olympics or an NCAA championship.Those changes are a normal part of cardiac adaptation, but they can often mimic heart problems.
In the Yale Sports Cardiology Program, which I lead, our experts are specially trained to read an echocardiogram, an MRI, and an EKG in athletes to differentiate normal adaptation from pathology. It’s essential to diagnose and avoid mis-diagnosing heart disease in athletes.
5. What led to your interest in returning to play?
Early in my career, I had two different patients who were athletes and diagnosed with different types of genetic heart problems. They both got defibrillators. At the time, the guidelines said that if a person has a defibrillator, they can’t play sports anymore.
One of my patients very astutely asked what data we had to back up those guidelines. I told him we didn’t have any data. He said, ‘Until you can show me data, I'm going to do what I want. If you get more data, I'll think about it.’”
That conversation sent me down a path to help athletes make decisions about continuing sports based on evidence rather than fear.
6. What research questions remain to help athletes with cardiac conditions make decisions about returning to sports?
There are still a lot of ongoing questions. In large prospective studies, we’ve only looked at two conditions, LQTS and hypertrophic cardiomyopathy, but there are many more.
We also need information on how to best treat and minimize risk in athletes with cardiac conditions. When are defibrillators the best choice, or when would medication or ablation be more effective? How can we make screening the most effective?
There will always be ongoing research on how to help keep athletes with cardiac conditions as safe as possible and back on the field whenever possible.
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