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EHRA Key References on Arrhythmias in competitive and recreational sports

Latest update May 2014

Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
Arrhythmias and Device Therapy


36th Bethesda Conference: eligibility recommendations for competitive athletes with cardiovascular abnormalities-general considerations. Task Force 7: arrhythmias.

Zipes DP, Ackerman MJ, Estes NA, 3rd, Grant AO, Myerburg RJ, Van Hare G.
J Am Coll Cardiol 2005;45:1354-1363.

North-american recommendations for competitive sports participation of athletes with arrhythmias, arrhythmogenic disorders, pacemakers or defibrillators.

Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.

Pelliccia A, Fagard R, Bjornstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, Borjesson M, Carre F, Corrado D, Delise P, Dorwarth U, Hirth A, Heidbuchel H, Hoffmann E, Mellwig KP, Panhuyzen-Goedkoop N, Pisani A, Solberg EE, van-Buuren F, Vanhees L, Blomstrom-Lundqvist C, Deligiannis A, Dugmore D, Glikson M, Hoff PI, Hoffmann A, Horstkotte D, Nordrehaug JE, Oudhof J, McKenna WJ, Penco M, Priori S, Reybrouck T, Senden J, Spataro A, Thiene G.
Eur Heart J 2005;26:1422-1445.

General guidelines paper from the Study Group on Sports Cardiology of the ESC concerning eligiblity for sports participation in athletes. This document not ony addresses arrhythmias but also eligibility of athletes with cardiomyopathies, hypertension, coronary heart disease, congenital anomalies, valvular disease and more. The recommendations are restricted to those performing competitive sports.

Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations revisited a comparison of U.S. and European criteria for eligibility and disqualification of competitive athletes with cardiovascular abnormalities.

Pelliccia A, Zipes DP, Maron BJ. J Am Coll Cardiol. 2008 Dec9;52(24):1990-6

In this article, the differences between the U.S. and European documents  for eligibility and disqualification are critically viewed, with special attention to genetic cardiovascular diseases relevant to sudden death in young athletes, through the prism of different cultural backgrounds, societal attitudes, and also perceptions regarding exposure to legal liability in the U.S. and Europe.

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions Part I: Supraventricular arrhythmias and pacemakers.

Heidbuchel H, Panhuyzen-Goedkoop N, Corrado D, Hoffmann E, Biffi A, Delise P, Blomstrom-Lundqvist C, Vanhees L, Ivarhoff P, Dorwarth U, Pelliccia A.
Eur J Cardiovasc Prev Rehabil 2006;13:475-484.

These recommendations document of the ESC Study Group on Sports Cardiology specifically address supraventricular arrhythmias but also give guidelines for those performing recreational sports. For different supraventricular arrhythmias and arrhythmogenic conditions, a description of the relationship between the condition and physical activity is given, stressing how arrhythmias can be influenced by exertion or can be a reflection of the (patho)physiological cardiac adaptation to sports participation itself. The following topics are covered: sinus bradycardia; atrioventricular nodal conduction disturbances; pacemakers; atrial premature beats; paroxysmal supraventricular tachycardia without pre-excitation; pre-excitation, asymptomatic or with associated arrhythmias (i.e. Wolff-Parkinson-White syndrome); atrial fibrillation; and atrial flutter. A related document discusses ventricular arrhythmias, channelopathies and implantable cardioverter defibrillators.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: Ventricular arrhythmias, channelopathies and implantable defibrillators.

Heidbuchel H, Corrado D, Biffi A, Hoffmann E, Panhuyzen-Goedkoop N, Hoogsteen J, Delise P, Hoff PI, Pelliccia A. Eur J Cardiovasc Prev Rehabilitation 2006;13:676-686.

This consensus paper on behalf of the ESC Study Group on Sports Cardiology addresses sports participation in competitive and recreational athletes in whom some form of ventricular rhythm disorder is documented (ventricular premature beats, nonsustained VT or sustained VT and VF), or when the patient is diagnosed to have inherited a pro-arrhythmic disorder (congenital and acquired long QT syndrome, short QT syndrome, Brugada syndrome, catecholaminergic polymorphic VT, arrhythmogenic right ventricular cardiomyopathy and other familial electrical disease of unknown origin). Also particular recommendations for patients/athletes with an ICD are discussed.

Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases.

Maron BJ, Chaitman BR, Ackerman MJ, Bayes de Luna A, Corrado D, Crosson JE, Deal BJ, Driscoll DJ, Estes NA, 3rd, Araujo CG, Liang DH, Mitten MJ, Myerburg RJ, Pelliccia A, Thompson PD, Towbin JA, Van Camp SP. Circulation 2004;109:2807-2816.

This position statements specifically addresses genetic cardiovascular diseases that are associated with increased risk for sudden cardiac death during exercise: hypertrophic cardiomyopathy, long-QT syndrome, Marfan syndrome, and arrhythmogenic right ventricular cardiomyopathy. It expands the recommendations from competitive athletes to the much larger population of patients who are not trained athletes but nevertheless wish to participate in any of a variety of recreational physical activities and sports. It contains a table with specific recommendations for many different types of sports, competitive or recreational.

Incidence and causes of sudden death in U.S. college athletes.

Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S. J Am Coll Cardiol. 2014 Apr 29;63(16):1636-43.

„In college student-athletes, risk of sudden death due to cardiovascular disease is relatively low, with mortality rates similar to suicide and drug abuse, but less than expected in the general population, although highest in African-American athletes. A substantial minority of confirmed cardiovascular deaths would not likely have been reliably detected by pre-participation screening with 12-lead electrocardiograms.”

Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: Data from an unselected nationwide study in Denmark.

Risgaard B, Winkel BG, Jabbari R, Glinge C, Ingemann-Hansen O, Thomsen JL,Ottesen GL, Haunsø S, Holst AG, Tfelt-Hansen J.Heart Rhythm. 2014 May 23. pii: S1547-5271(14)00557-8.

„The incidence rates of sport related SCD in noncompetitive and competitive athletes are not different. The study showed an increase in the incidence rate of sport related SCD in persons aged 36-49 years in both noncompetitive and competitive athletes compared to those aged 12-35 years. Importantly, SCD in the general population is much more prevalent than is sport related SCD in all age groups.”

Incidence of cardiovascular sudden deaths in Minnesota high school athletes.

Maron BJ, Haas TS, Ahluwalia A, Rutten-Ramos SC. Heart Rhythm. 2013 Mar;10(3):374-7.

„In this high school athlete population, risk of cardiovascular SD was small, in the range of 1:150,000 participants/year. Based on autopsy data, only about 30% of the SDs were due to diseases that could be reliably detected by preparticipation screening, even with 12-lead electrocardiograms.”

Risk of sports: do we need a pre-participation screening for competitive and leisure athletes?

Corrado D, Schmied C, Basso C, Borjesson M, Schiavon M, Pelliccia A, Vanhees L, Thiene G. Eur Heart J. 2011 Apr;32(8):934-44.

Comparison of U.S. and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies.

Maron BJ, Haas TS, Doerer JJ, Thompson PD, Hodges JS. Am J Cardiol. 2009 Jul 15;104(2):276-80.

Despite different preparticipation screening strategies, athlete sudden death rates in these demographically similar regions of the United States and Italy have not differed significantly Study data do not support a lower mortality rate associated with preparticipation screening programs involving routine electrocardiography and examinations by specially trained personnel.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete.

Corrado D, Pelliccia A, Heidbuchel H, Sharma S, Link M, Basso C, Biffi A, Buja G, Delise P, Gussac I, Anastasakis A, Borjesson M, Bjørnstad HH, Carrè F, Deligiannis A, Dugmore D, Fagard R, Hoogsteen J, Mellwig KP, Panhuyzen-Goedkoop N, Solberg E, Vanhees L, Drezner J, Estes NA 3rd, Iliceto S, Maron BJ, Peidro R,Schwartz PJ, Stein R, Thiene G, Zeppilli P, McKenna WJ; Section of Sports Cardiology, European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J. 2010 Jan;31(2):243-59

The paper represents a consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease.

Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry.

Lampert R, Olshansky B, Heidbuchel H, Lawless C, Saarel E, Ackerman M, Calkins H, Estes NA, Link MS, Maron BJ, Marcus F, Scheinman M, Wilkoff BL, Zipes DP, Berul CI, Cheng A, Law I, Loomis M, Barth C, Brandt C, Dziura J, Li F, Cannom D.  Circulation. 2013 May


„Many athletes with ICDs can engage in vigorous and competitive sports without physical injury or failure to terminate the arrhythmia despite the occurrence of both inappropriate and appropriate shocks. These data provide a basis for more informed physician and patient decision making in terms of sports participation for athletes with ICDs.”