Return to play? Athletes with
congenital long QT syndrome

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
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

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
by: Jeffrey Driban


Johnson JN, & Ackerman MJ (2013). Return to play? Athletes with congenital long QT syndrome. British Journal of Sports Medicine, 47 (1), 28-33 PMID: 23193325