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Life after a cardiac event can be difficult for patients to adjust to, especially for athletes. The decision to return to play is important and must be made by weighing the risks and benefits for each person. Michael Emery, MD, Co-Director of the Sports Cardiology Center, talks about considerations for return to play and the shared decision-making process.

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Return to Play: A Cardiac Event Doesn't Always Mean the End

Podcast Transcript


Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Michael Emery, MD:

I'm going to talk about the risk of participation, and this really stems, and I think this case highlights everything in my talk in one single case. A lot of us remember Christian Eriksen's collapse from sudden cardiac arrest on the pitch during Euro 2020 when he was playing for his native country of Denmark. This was live on international television. I know my phone went off as soon as this happened by many of my colleagues texting me about this, and thankfully, he survived. This has been highlighted. Emergency action plans saved his life, rapid defibrillation and rapid action. So, this is a great case of survival.

There's a lot of controversy in this. Screening we've talked about. Mr. Eriksen was screened multiple times before his event. They've never really come up with an etiology, that's been publicly announced, at least. And now, just 259 days afterwards, he's talking about returning to the pitch, and his goal of playing in the World Cup for his native Denmark.

After this story, he scored his first goal, again, playing sports after sudden cardiac arrest, with a defibrillator. So cardiac arrest in relationship to vigorous activity, well, we think it's a real thing. This is a nice study on cardiac arrest during long distance running events, it's called the RACER Study. There were nearly 11 million runners, and the incidence during marathons and half-marathons, there was about one cardiac arrest or one cardiac death per 200,000 race participants, higher in marathons, about 1 in 100,000, and less in half-marathons. For unclear reasons, had male sex predominance. The etiologies here, hypertrophy, cardiomyopathy, myocardial ischemia. You're more likely to survive if you're ischemic than if you had some underlying congenital or cardiomyopathic process.

This brings us to the risk of sudden cardiac death during activity, and this paper from 2020 really highlights that any activity increases your risk of sudden cardiac arrest, of sudden cardiac death while you're participating in that activity. The more habitual your activity is, the less your risk goes up during that. And in fact, the more habitual your activity, your risk of sudden cardiac death during the other 23 hours of the day that you're not doing anything is much lower. So being that weekend warrior who never does anything and trying to go hit it hard all of a sudden increases your risk dramatically more than if you're habituated to vigorous activity. Think of that sedentary person who decides to shovel snow in the winter. This is one of the reasons why, amongst a few others.

So, does sport act activity enhance the risk of sudden cardiac death? This was a study from Italy about 20 years ago now, and what they showed was that the relative risk of an athlete suffering a cardiovascular event compared to a non-athlete was about three folds higher while they're participating in sports, whereas the risk of non-cardiovascular death did not go up significantly.

But is it sport, per se? Probably not sport per se. It's the vigorous activity in someone with an underlying predisposition. These are different various conditions, ARVC through conduction system disorders, showing that it's the disorder coupled with the vigorous activity that increases the risk, not necessarily the sport itself.

Well, once you've been diagnosed with a cardiac condition, what about returning to play? This is the classically one quoted return-to-play guidelines, and these were published in 2005. Well, these were updated in 2015 for the ACC and the American Heart Association, and the overlying goal of return-to-play guidelines are the protection of athlete's health and avoidance of undue risk are the primary factors in forming clinical judgment and recommendations of the managing physician. So, this is helpful when we are trying to decide how to counsel a patient or what we would recommend to a patient or a school for someone that has a diagnosed cardiac condition. This is 16 different documents, 15 task force, hundreds of pages, hundreds of diagnoses. There are nine of these task forces that highlight specific cardiac conditions and six of these task force about varying things such as classification of sport, which we've seen, pre-participation evaluations, performance enhancing drugs, emergency action plans, Commotio cordis and legal aspects, which are important.

The European Society of Cardiology published their own updated guidelines in 2020. Their guidelines are a little bit different because they focus more on just sport, per se. They talk about exercise for health and wellbeing in the general population. They start introducing the concept of shared decision making into their guidelines, risk stratification and include other things besides cardiac conditions such as pregnancy and athletes with disability.

I mentioned the medical/legal, and I think this is important to highlight here. This is from the late 1990s, and we could spend an entire hour talking about these legal cases. But suffice to say that because of this case, judicial precedent was provided and set regarding the role of, at the time, 36th Bethesda Conference recommendations in resolving legal issues relating to athletic participation and disputes. And most importantly, courts generally have recognized that guidelines established by national medical associations are evidence of good medical practice. And I want to highlight good medical practice, but they are not conclusive evidence of medical legal standard of care, and there's distinctions there that need to be made and are important.

So again, bringing back to the 36th Bethesda Conference in return-to-play, and this starts to bring us into the shared decision-making process. The 36th Bethesda Conference, again, 2005, were in the older era of guidelines, and really, they were, yes, you can play, no, you can't play. They were very binary. Whereas in the 2015 updated guidelines, the ACC and the AHA had introduced the level of evidence and the classification. So, it wasn't just about yes or no, it was about how strong the recommendations are and how strong the data behind it are.

These 2015 guidelines included 253 diagnoses in clinical scenarios, all levels of evidence C, you remember level of evidence C is very limited population data, mostly driven by expert opinion. But within that there were 84 class II recommendations. So, class I, green, pretty much good to go, class III, harmful or not recommended, and class II brings about more nuanced. So no longer is it thumbs up, thumbs down, yes or no, binary. We have, it is reasonable and may be considered. So that inherently introduces a scenario where there's discussion involved.

This was highlighted by this great letter to the editor by some colleagues in 2017 about a call for a paradigm shift in clinical decision making in athletes and what they specifically state, the time has come to acknowledge with full transparency that sport participation among athletes with cardiovascular disease is a complex clinical topic that remains shrouded in persistent scientific and clinical uncertainty, and simplified yes versus no decisions are almost always suboptimal and our young athletes really deserve more.

This brings this into the era of shared decision making and how do we discuss shared decision making from sports cardiology pillars. This is important and we're going to spend some more time on this. There are five pillars that really decide and help us understand shared decision making. One is knowledge. What's the appropriate diagnosis? Has the appropriate diagnosis been made? Are you an expert in that condition? Are you an expert in sports and recommendations? Do you have the knowledge to make this decision, knowledge to share it, and the risks with that person? Are you the right person? Humility. Recognizing that you may not be able to provide that expert counsel. You may not be an expert in that disease even though you may be an expert in sports cardiology, and you have to bring in other experts to help you and assist you. Bring in other opinions. Recognizing that science can change. We've seen those winds of change. Appreciate that the physician is there to serve the patient, not to parent the patient per se. Respect. Respect the patient's priorities and recognize the patient's voice and opinion. Teamwork. Approach the patient as a teammate and a fellow expert. Engage and discuss with the patient's significant others. There is other third parties often involved in this. And communicate, communicate with the patient, with the parents, with the school.

All these five pillars, knowledge, humility, respect, teamwork, communication, have to factor into a shared decision-making approach. It's not a rubber stamp. That's not what shared decision making is about. It's not rubber-stamping you can play. It involves an athlete with disease, it involves a physician, it involves a third party, oftentimes. Third parties aren't necessarily involved in the discussion upfront, but they have to be involved in the implementation of any shared decision-making approach.

Some potential pitfalls. Differences in valuations of an athletic lifestyle between a physician and an athlete. That's an important piece. Often athletes with cardiovascular disease seek out sports cardiologists because of that valuation effort. Biases and heuristics. Clouding communication and appreciation of risk. That implicit bias. Differences in perception and interpretation of risks. I may not interpret the risk the same way someone else. And medical legal biases. This leads us to athlete centered decision making regarding sports eligibility and participation.

A few take home points here. One, sports, per se, are not a cause of enhanced mortality, but it can trigger sudden death in a susceptible athlete. Guidelines for participation in sports with cardiovascular disease serve as a framework to discuss return-to-play and risk is not a mandate. Shared decision-making shifts away from the binary process of sports disqualification, involving equal participation from the athlete at other key stakeholders. Thank you.


Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen clevelandclinic.org/cardiacconsultpodcast.

Cardiac Consult

Cardiac Consult

A Cleveland Clinic podcast exploring heart, vascular and thoracic topics of interest to healthcare providers: medical and surgical treatments, diagnostic testing, medical conditions, and research, technology and practice issues.

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