ACC.25 Presentation—Arrhythmias in Athletes: Management and Return to Play
In this video, Rachel Lampert, MD, Robert W. Berliner Professor of Medicine at the Yale School of Medicine, reviews her presentation at the American College of Cardiology 2025 Annual Meeting, “Arrhythmias in Athletes: Management and Return to Play.” In her presentation, Dr Lampert examines the Heart Rhythm Society guidelines that specifically address arrhythmias in athletes and how the guidelines shift the focus from if an athlete can return to play to how we can safely get them back on the field.
Additional Resources: Lampert R, Chung EH, Ackerman MJ, et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play. Heart Rhythm. 2024;21(10):e151-e252. doi:10.1016/j.hrthm.2024.05.018
Transcript:
Rachel Lampert, MD: I am Dr. Rachel Lampert. I'm the Berliner Professor of Medicine at Yale School of Medicine, and I'm an electrophysiologist and the director of Sports Cardiology.
Consultant360: Can you please describe the key themes of your presentation?
Dr Lampert: So I was so glad to have had the opportunity at ACC to talk about our recent Heart Rhythm Society document, a Professional Society recommendations document that was done in collaboration with a number of other societies about arrhythmias in the athlete, evaluation management and return to play. So this was the first document to specifically address these issues in athletes. Why did we need that document? Well, the arrhythmias that athletes get are not different from the arrhythmias that may occur in the general population, but athletes themselves are different. And that leads to specific considerations as far as how we approach the evaluation and the management. And then of course, questions about how to return to play. One place where this document really differs from prior documents about athletes is that we're really focusing here, not so much on can an athlete with a specific heart condition return to play, but really how can we facilitate that athlete's return to play?
When we're thinking about evaluation, their most important is that we need to understand what is the normal adaptation of the heart to intensive vigorous exercise strength or anaerobic types of exercise creates thicker walls. Endurance exercise often leads the chambers to dilate, and it's very important as we're evaluating athletes to understand those adaptations so we know what's normal because a lot of those can overlap with pathologies, things like cardiomyopathy. So that's the first point in evaluation. We also need to think about the question of, as these athletes are being evaluated, whether it's for palpitations, syncope, can they be returning to play, or do we need to hold them out? And in fact, that varies. It really depends on what we're thinking about. So if an athlete presents with PVCs, that's something that we're really going to want to evaluate. Understand, are these going to be benign PVCs?
Could these be reflective of an underlying, more significant abnormality? And we may hold that athlete out while we're doing that evaluation. On the other hand, the athlete found to have Wolff Parkinson White, perhaps on a pre-participation screening. We may let them go back after an echo to make sure nothing else is going on, because we know in that entity arrhythmic events are not necessarily happening during exercise anyway. So it really varies from entity to entity, whether we're letting them go back. So what about the management of arrhythmias? When we're thinking about how to treat arrhythmias in the athlete, we need to take into account both what the entity itself, but also what impact the treatments are going to have on that person's goals for all patients. We should be doing what we call shared decision making these days. It used to be that doctors just told the patient what to do these days.
It's a conversation. We ask the patient, what are your preferences? What are your goals, your values? And we then talk about the options for treatment in the context of that person's goals. So for an athlete, often the goal is to get back to their prior sports performance and generally, and generally as quickly as possible, usually by yesterday. So as we're thinking about how does this impact our treatment choices, so a couple of examples. So for example, if an athlete has had a cardiac arrest, they're getting a defibrillator these days, we have a lot of choices of types of defibrillators, transvenous, subcutaneous, newer extravascular, and we really need to think what sport do they do? How does the sport influence what type of device? We may want to give them another place where management may be different. For athletes, many arrhythmic entities are treated with beta blockers.
And while many athletes, just like many people tolerate beta blockers, fine for some athletes, it does make people feel more tired. And we may be moving to alternative therapies perhaps sooner than we might in other individuals, such as moving from a medication to perhaps a procedure like a cardiac sympathetic. And again, this isn't a prescription. This is about options that we're talking about with athletes as we're talking about management options as their course progresses. Another place where we may be thinking about athletes differently, antirrhythmic drugs can be problematic in all patients, but for athletes, both the fast heart rates they have when they're exercising, the slower heart rates they have when they're not exercising because of the good physical condition they're in, may bring out the arrhythmic aspects of the anti-arrhythmic drugs we have. So we may think about ablation, a procedural approach that would remove the need for anti-arrhythmic drugs. So those are all some places where management may differ. And I think, again, I'd like to emphasize as I did at the beginning, what really makes this document different than prior is that we're really focusing for all of these questions, not just on can this person go back to play or not, but really how can we evaluate and manage them in the way that most will facilitate getting them back on the field or in the pool if that's where they want to be.
C360: What are the gaps in our knowledge that remain on this topic and the areas for future research?
Dr Lampert: So as the field of sports cardiology and sports electrophysiology is expanding, we're getting more and more data to guide how we think about athletes. But we still, there's still so many places where we need to collect more data. So I'll just emphasize some. We have these newer ICDs. How subcutaneously extravascular, how will those play into the management of athletes? One place where we are really short on research is how will vigorous, how does vigorous exercise in competitive sports impact the progression of some cardiomyopathies, such as hypertrophic cardiomyopathy or A RVC? And finally, while we have thoughts, while we can present different options to the patients, for example, drugs versus ablation, we really don't have data to guide that decision. And so I think I'm really looking forward to the next years, next decade as we expand our knowledge base in this population.