Refining the Risk: Sports for Young Patients with Implantable Cardioverter Defibrillators

Despite a dearth of research, published guidelines (based on expert opinion) in the United States and Europe have recommended against competitive sports participation in activities more strenuous than bowling or golf (Class IA) for patients with pacemakers or implantable cardioverter defibrillators (ICDs).1,2 For the benefit of our young patients, we were recently able to change opinions and the U.S. guidelines about sports participation for children and young adults with ICDs.3 This change was based on research done at Cleveland Clinic and Cleveland Clinic Children’s along with other international centers.4, 5

In 2006, a prospective multicenter registry was launched to study the safety of sports participation for patients with ICDs. This international investigation included patients from ages 10 to 60 who received ICDs for primary or secondary prevention of sudden cardiac death. Investigators from Cleveland Clinic pushed to include young patients in this very important groundbreaking study.

Diagnoses include inherited arrhythmia syndromes, inherited or acquired cardiomyopathies, congenital heart disease and valvular heart disease. The first published results from this registry indicated that 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,4 and the final long-term results published in 2017 confirmed the safety of participation for even the youngest patients with ICDs.5 Patients’ choice of athletics included running, alpine hiking, swimming, skiing, snowboarding, rock climbing, basketball, football, baseball, gymnastics and other sports both at the college levels (D1, D2, and D3) and high school varsity and junior varsity levels.

A previous study I authored included 21 pediatric and adult congenital heart patients with ICDs who regularly participated in competitive or vigorous sports. This data also indicated no mortality and no increase in morbidity after four years.6 Patients’ choice of athletics included running, jogging, alpine hiking, swimming, skiing, snowboarding, rock climbing, basketball, football, baseball, gymnastics and other sports. One teen with congenital heart disease did experience two appropriate ICD shocks for treatment of ventricular tachyarrhythmias during basketball and then decided to withdraw from competitive athletics.

Similar to the Multinational Sports Registry, no other patients had an increased incidence of ICD therapies during athletics, either inappropriate or appropriate, and there was no increased rate of damage to the ICD system during organized sports. Of note, most of patients with ICDs were on beta blocker therapy to prevent inappropriate ICD shocks due to sinus or supraventricular tachycardias, and most underwent formal exercise testing to screen for arrhythmia prior to sports participation.

When questions arise about sports participation, it is our practice to counsel patients and families about the risks, including potential for increased rate of ventricular tachyarrhythmias and damage to the pacemaker or ICD system. Counseling is patient-specific; the underlying cardiac disease, type of device, indication for implant, position of leads and pulse generators, underlying heart rhythm, patient age, and type of athletic activity are considered when estimating risk.

The potential benefits of sports participation for young patients include decreased risk for obesity, metabolic syndrome, coronary and peripheral artery disease, stroke and diabetes.7 There are additional benefits of exercise, including a positive effect on general mental health, decreasing risk for depression and overall improvement in wellbeing, all of which affect quality of life.8 Ultimately, the importance of sports participation to each patient’s quality of life must be estimated by the individual and their family.

In summary, the risk of sports participation for our patients with implanted cardiac devices may include an increased tachyarrhythmia burden, injury after loss of consciousness from cardiac device function or malfunction, and permanent damage to the implanted device system during sports. Sports that evoke a high potential for serious injury to self or others if a patient were to experience syncope, including those using motor vehicles, should be discouraged. In the future, our estimates of risk should be guided by research rather than opinion. The risks of sports participation must be weighed against the benefits, including potential for improved quality of life, for all young patients with implanted cardiac devices.

Dr. Saarel is a pediatric and congenital cardiologist at Cleveland Clinic Children’s where she has served as Chair of Pediatric Cardiology since 2015. She is a Professor of Pediatrics at the Cleveland Clinic Lerner College of Medicine at Case Western University and the Ronald and Helen Ross Distinguished Chair holder in Pediatric Cardiology.

References

1. Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing committee to develop guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death). J Am Coll Cardiol 2006; 48(5): e247-346.
2. Pelliccia A, et al. Implantable cardioverter defibrillator and competitive sport participation. Eur Heart J 2009; 30(24): 2967-8.
3. Maron BJ, Zipes DP, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities. J Am Coll Cardiol 2015; Nov 2:[Epub ahead of print].
4. Lampert R, Olshansky B, Heidbuchel H, Lawless C, Saarel E, Ackerman M, Calkins H, Estes NAM, Link MS, Maron BJ, Marcus F, Scheinman M, Wilkoff BL, Zipes DP, Berul CI, Cheng A, Jordaens L, Law I, Loomis M, Willems R, Barth C, Broos K, Brandt C, Dziura J, Li F, Simone L, Vandenberghe K, Cannom D.Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation 2013; 127(20): 2021-30.
5. Lampert R, Olshansky B, Heidbuchel H, Lawless C, Saarel E, Ackerman M, Calkins H, Estes NAM, Link MS, Maron BJ, Marcus F, Scheinman M, Wilkoff BL, Zipes DP, Berul CI, Cheng A, Jordaens L, Law I, Loomis M, Willems R, Barth C, Broos K, Brandt C, Dziura J, Li F, Simone L, Vandenberghe K, Cannom D. Safety of Sports for Athletes With Implantable Cardioverter-Defibrillators: Long-Term Results of a Prospective Multinational Registry. Circulation. 2017 Jun 6;135(23):2310-2312. doi: 10.1161/CIRCULATIONAHA.117.027828.PMID: 28584032
6. Saarel EV, Gamboa, D, Etheridge SP, Sports for young patients with implantable cardioverter-defibrillators: Refining the risk. J Am Coll Cardiol 2014; 63(12): a128.
7. Lloyd-Jones D, et al. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation 2010; 121(7): e46-e215.
8. Landers, D, The influence of exercise on mental health. The President’s Council on Physical Fitness and Sports 1997: 2(12).