Return to play? Athletes with congenital long QT syndrome
Johnson, J, Ackerman, M. Br J Sports Med 2013 Jan;47(1):28-33. doi: 10.1136/bjsports-2012-091751. Epub 2012 Nov 28
The current Bethesda and the European Society of Cardiology (ESC) guidelines are used to determine the cardiac risk of athletes’ participation with long QT-syndrome (LQTS). While the Bethesda guidelines stratify athletes with LQTS into different classes the ESC strictly prohibits athletes with LQTS from sport participation. Johnson and Ackerman looked at these rather strict guidelines by examining outcomes among patients that chose to continue sport participation after being diagnosed with LQTS. A retrospective chart analysis of patients with LQTS ages 6 through 40 years at their initial evaluation was performed. Extracted data from the medical records included athletic participation after diagnosis of LQTS and events related to LQTS such as syncope, seizures, documented ventricular arrhythmias, aborted cardiac arrest, or sudden death. To ensure the patients and families could make an informed decision on continued safe athletic participation every patient underwent an extensive four step program. The first step, which was universal for every patient with LQTS, was a two to three day evaluation of their cardiac status, including electrocardiography, echocardiography, cardiac stress testing, 24 hour ambulatory monitoring, and implementation of a treatment plan. For athletes additional counseling was provided for continued sports participation. The second step was that both parents and the pediatric athlete needed to agree on participation. Implementing the best-available evidence-based medicine for athletes that participated in sports despite the Bethesda recommendations was the third step. The last step was that athletes with LQTS acquire an automatic external defibrillator and add it to their game bag. Between July 2000 and November 2012, 353 patients were identified among which 157 (44%) were athletes. Following their evaluation, 130 (83%) athletes chose to continue with their sports participation. 60 (46%) athletes were participating in sports contrary to both the Bethesda and ESC guidelines of which 20 (33%) athletes had an implantable cardioverter defibrillator. Another 70 (54%) athletes were only in compliance with the Bethesda recommendations. All 130 athletes participated in a wide array of sports and across several Bethesda sport classifications without the incidence of death. Further, the authors found no differences in the incidence of LQT- triggered cardiac events among the 130 athletes compared to the 223 patients with LQTS that did not participate in sports.
Though the findings in this study are promising they need to be viewed with caution, because of the small number of study patients and difficulty applying these findings to the general patient population given the very meticulous and stringent follow up. As pointed out by Drezner in this editorial, this study is a landmark study. The above study and its newly presented data can serve as a starting point for additional research. Further, these findings will not only improve the care for athletes with LQTS but could potentially lead to a revision of the Bethesda guidelines. After all, these guidelines are based on professional expertise because the scientific evidence is limited. The new guidelines may be less restrictive for athletes with LQTS as well as incorporate informed/ guided decisions about participation from parents and athletes alike. Can a newly designed management protocol effectively be applied and implemented? How will these new findings influence your clinical practice?
Written by Christian Glaser, DO
Reviewed by: Jeffrey Driban