14 Jun 2020 ESC guidelines on sports cardiology part 4
How exercise professionals can use the 2020 ESC guidelines part 4: arrhythmias including atrial fibrillation and atrial and ventricular tachycardias, long QT and Brugada syndrome; implantable cardioverter defibrillators
In part four of my summary of the 2020 European Society of cardiology guidelines for exercise professionals, I’ve summarised for you the guidelines on arrhythmias including atrial fibrillation, supra ventricular tachycardias (SVT), long QT and Brugada syndrome, and automated implantable cardioverter defibrillators (AICD).
Atrial fibrillation: I have produced a large amount of material on this topic, and I will not be going over that here. But going to the ESC recommendations: AF ablation is recommended in individuals who are wanting to exercise and have recurrent symptomatic AF +/- in those who don’t want to undergo drug therapy, given its impact on athletic performance. The ventricular rate while exercising with AF should be considered in every exercising individual by symptoms +/- ECG monitoring and titrated rate control should be instituted (under medical supervision). Cavo-tricuspid isthmus ablation should be considered in those with documented atrial flutter who want to engage in intensive exercise to prevent atrial flutter with 1:1 atrioventricular conduction leading to dangerously high ventricular rates.
Supraventricular tachycardia SVT: ablation of an accessory pathway(s) is recommended in competitive and recreational athletes with pre-excitation +/- documented arrhythmias. In competitive +/- professional athletes with a symptomatic pre-excitation, an EP study is recommended to evaluate the risk for sudden cardiac death. In competitive athletes with paroxysmal SVT but without pre-excitation, curative treatment by ablation should be considered. Among individuals with frequent ventricular ectopics and non-sustained ventricular tachycardia, a thorough investigation with ambulatory monitoring, 12 lead ECG, and imaging is recommended.
Long QT syndrome: it is recommended that all exercising individuals with long QT syndrome with prior symptoms or prolonged QT be on therapy with beta-blockers at the target dose. Shared decision-making should be considered regarding sports participation in patients with genotype-positive, phenotype-negative LQTS that is less than 470 ms in men and less than 480 ms in women. Participation in high intensity recreational and competitive sports, even when on beta-blockers, is not recommended in individuals with a QTC greater than 500 ms, or a genetically confirmed LQTS with a QTC greater than 470 ms in men or 480 ms in women. Participation in competitive sports with or without an automated implantable cardioverter defibrillator (AICD) is not recommended in individuals with LQTS and prior cardiac arrest or an arrhythmic syncope.
Brugada syndrome: implantation of an automated implantable cardioverter defibrillator is recommended in patients with Brugada syndrome who have had episodes of arrhythmic syncope +/- sudden cardiac arrest. Following implementation of an AICD, resumption of leisure or competitive sports should be considered after shared decision-making in individuals who have not experienced recurrent arrhythmias over the previous three months after implementation of an AICD. Automated implantable cardioverter defibrillators (AICD): ambulatory recordings and device interrogation during and after resuming sports should be considered to allow appropriate tailoring of rate-responsive pacing parameters. It is recommended that individuals within any implantable device with or without resynchronisation and underlying disease follow the recommendations pertaining to the underlying disease and the device. Participation in sport and exercise, except collision sports, should be considered in individuals with pacemaker therapies and AICDs, so long as they do not have pathological substrates for fatal arrhythmias. Prevention of direct impact can be affected to the implanted device by adapting the site of lead and or device implantation using padding, or simply by the restrictions imposed on direct contact via the laws of the sport. An AICD is not recommended as a substitute for disease related recommendations when these are applied to competitive sports. In other words, clinical advice and clinical reasoning always trumps any assumption that an AICD will adequately protect the individual in all situations.