History of the Recommendations for Eligibility and Disqualification

Participation in competitive athletics has increased dramatically in the past decade. Ranks of participating athletes have swelled to more than 35 million youth (ages 5-18 years participating in organized sports of all types), nearly 8 million high school varsity athletes, and 500,000 collegiate athletes in the United States alone. Beyond the collegiate years, participation in organized and competitive athletic events has also increased, as exemplified by the tremendous increase in adults completing a marathon (14 million in 2011 versus 5 million two decades before).¹

Included in these increasing ranks of competitive athletes are increasing numbers of athletes with cardiovascular (CV) abnormalities. These abnormalities may have been previously recognized or may be clinically silent, and may be either congenital or acquired. There are now more than 1 million adults living with congenital heart disease.² There is now widespread use of genotyping to identify patients with inherited cardiovascular disease, creating a new class of "genotype positive" athlete that may or may not have the phenotype of the inherited abnormality.

Patients with congenital or acquired CV abnormalities that have been surgically corrected, medically treated, or provided with prophylactic measures via drugs or devices seek guidance from their health providers on the risks and benefits of participation in competitive athletics.

The American College of Cardiology (ACC) convened a series of meetings to address the issue beginning in 1985 and published a series of "Bethesda Conferences" on the topic, convening every 10 years. Bethesda #36 in 2005 was the last.³ The face-to-face conferences no longer take place, and the process has transformed into a series of expert consensus documents jointly produced by the ACC and the American Heart Association (AHA), following the rigorous methods and policies for scholarship, peer review and freedom from conflict of interest specified by those organizations.⁴

What is New in this Document?

The need for an update was driven by multiple factors: 1) advances in knowledge of the mechanisms of disease, new diagnostic modalities, new devices for the prevention of sudden cardiac death, and new treatments. 2) Changes in the athletes and the sports – bigger athletes, more extreme sports, changes in training, and the use of performance enhancing drugs. 3) Advances in CV genetics. 4) Continued gaps in knowledge about the natural history of athletes with CV abnormalities, and the best practices for protecting them from adverse consequences of participation in competitive athletics.

The current recommendations include the work of 15 Taskforces, contributions by 31 authors, and reviews by peers across sections, councils and committees from both the AHA and the ACC. Nine documents are related to specific disease states, and the other 6 Taskforces dealt with topics across the continuum, from screening strategies to the legal aspects of the medical decision making process (Table 1).

Task Force by Title

Classification of Sport: Dynamic, Static and Impact Preparticipation Screening for Cardiovascular Disease in Competitive Athletes Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy and Other Cardiomyopathies, and Myocarditis Congenital Heart Disease Valvular Heart Disease Hypertension Aortic Disease, Including Marfan Syndrome Coronary Artery Disease Arrhythmias and Conduction Defects The Cardiac Channelopathies Drugs and Performance Enhancing Substances Emergency Action Plans, Resuscitation, CPR, and AEDs Commotio Cordis Sickle Cell Trait Legal Aspects of Medical Eligibility and Disqualification Recommendations

The intended audience for this document is the provider faced with an athlete and the need for a decision regarding initial participation in competitive sports or return to competition. These providers may be cardiologists, but also may be from other specialty backgrounds, or generalists serving as team physicians or providing primary care to athletes. The task force recognized that cardiologists would not be making all of the decisions, perhaps not even a majority of the decisions on eligibility or disqualification, and has proposed general guidance that can be utilized by any qualified provider. For the first time; however, consideration is given to the role of specialized centers in management of uncommon or complex abnormalities. Congenital long QT syndrome is an example where a body of evidence is forming around the role of such specialized centers.⁵

As with many clinical consensus documents, the majority of the recommendations are not based on the results of randomized clinical trials, but instead represent the consensus of opinion from experienced clinicians in the field. The need for additional data regarding outcomes of athletes participating in competitive sports is ongoing, and randomized trials are not practical in many situations.

How to Use the Document

Recommendations by the Taskforces are grouped by disease states, and the recommendations conform to the Category of Recommendation and Level of Evidence standards of the ACC/AHA Taskforce on Practice Guidelines. Thus, the recommendations are categorized as actions that should be performed, are reasonable, or should not be performed. As with all consensus documents, there is assumed to be an accurate diagnosis. For example, disqualification standards intended for athletes with hypertrophic cardiomyopathy should not be used to determine the eligibility of an athlete with physiologic hypertrophy (a normal athlete's heart).

The Taskforces recognizes that there are many definitions of "athlete", and attempts to confine the recommendations to athletes participating in an organized team or individual sport, largely focused on student-athletes 12-25 years of age. However, there are numerous athletes needing guidance who do not conform to those definitions, and this is where good clinical judgment plays an important role. The Taskforces recognizes that there are unique professions, such as firefighters, that are required to face unusual CV stresses. Although some of the same principals may apply to athletes and these special professions, there are insufficient data to recommend extrapolating from athletes to other professions.

Several Taskforces deal with overarching themes, such as classification of sports and the legal aspects of eligibility and disqualification. Users of this document should be very familiar with these overarching principals, as they apply to the specific sport and athlete for which they are making a decision. A clear message is to understand in detail the sport itself: in any given sport, the position played or physical demands may place quite different stresses on the athlete. Training programs, seasons of the year, and level of competition all should be known in detail. The decisions for high-profile professional athletes will often be made based on factors not relevant to the scholastic level. Clinicians must understand all aspects of the situation, but must also make the patient the center of the decision-making.

The Future

There will undoubtedly be another iteration of this document. It should be informed by new data, hopefully from appropriately controlled clinical trials; however, when not practical, it should be data drawn from observational studies, registries and big data on population health.

Registries of athletes participating in competitive sports will provide important new information, and several already have.⁶ Registries provide unique longitudinal information when randomized trials are not practical. Registries in this population can be challenging, when considering that athletes move through a diverse system of clubs, schools and leagues. The athletes also move from place to place and institution to institution, creating issues of identification, tracking, and privacy. Barriers to data gathering into registries must be lowered, perhaps by leveraging the use of the internet and social media, as has been applied to other uncommon cardiac disorders.⁷

Competencies will be developed to guide the training of sports cardiologists. Systems of care will be developed to provide high quality and efficient care for all athletes, regardless of their location or financial resources.

This new generation of sports cardiology providers will need these large documents transformed into usable mobile applications that will aid decision making at the point of care.

References

1. Lawless CE, Asplund C, Asif IM, et al. Protecting the Heart of the American Athlete: proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank October 18, 2012, Washington, DC. J Am Coll Cardiol 2014;60:2146-71.
2. Congenital Heart Defects (CHDs) (CDC website). Available at: http://www.cdc.gov/ncbddd/heartdefects/data.html. Accessed 03/15/2016.
3. Maron BJ, Zipes DP. 36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005;45:1312.
4. Methodologies and Policies from the ACC/AHA Task Force on Practice Guidelines. Available at: http://my.americanheart.org/professional/StatementsGuidelines/PoliciesDevelopment/Development/Methodologies-and-Policies-from-the-ACCAHA-Task-Force-on-Practice-Guidelines_UCM_320470_Article.jsp. Accessed 03/15/2016.
5. Johnson JN, Ackerman MJ. Competitive sports participation in athletes with congenital long QT syndrome. JAMA 2012;308:764-5.
6. Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation 2013;127:2021-30.
7. The "Virtual" Multicenter Spontaneous Coronary Artery Dissection (SCAD) Registry (SCAD) NCT01429727. Available at www.clinicaltrials.gov. Accessed 03/15/2016.

Keywords: Adolescent, Aortic Diseases, Arrhythmias, Cardiac, Arrhythmogenic Right Ventricular Dysplasia, Athletes, Cardiomyopathy, Hypertrophic, Cardiopulmonary Resuscitation, Channelopathies, Commotio Cordis, Consensus, Coronary Artery Disease, Death, Sudden, Cardiac, Genotype, Heart Conduction System, Heart Valve Diseases, Hypertension, Hypertrophy, Long QT Syndrome, Marfan Syndrome, Myocarditis, Performance-Enhancing Substances, Phenotype, Primary Health Care, Randomized Controlled Trials as Topic, Registries, Risk Assessment, Sickle Cell Trait, Sports

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