New answers to questions about sports safety and heart issues

Experts have new advice for athletes with heart conditions – and on how doctors and patients should work together to weigh the risks of competitive sports.

Cardiovascular abnormalities usually disqualify people from competitive sports. But a new report from the American Heart Association and the American College of Cardiology summarizes recent evidence that athletes of all ages often may safely participate despite certain heart abnormalities or diseases.

The report was published Thursday as a scientific statement in the AHA journal Circulation and in the Journal of the American College of Cardiology.

The statement reviews best clinical practices for athletes, from children to adults, said Dr. Jonathan H. Kim in a news release. Kim, an associate professor of medicine and director of sports cardiology at the Emory University School of Medicine in Atlanta, led the panel of experts who wrote the statement.

The authors defined competitive athletes as "professional and recreational athletes" who put a premium on achievement and train for team or individual activities, including marathons and triathlons.

The last scientific statement on the "athlete's heart" was issued in 2015. Studies in the past 10 years about congenital heart defects, arrhythmias and other heart conditions indicate that the risks during competitive sports are not as high as previously thought, although they are real.

"We acknowledge that there are times when the risks of competing are much higher than the benefits for athletes with cardiovascular abnormalities," Kim said. But the update provides tools for a discussion about weighing risks and rewards, he said.

The statement emphasizes the importance of shared decision-making in determining what's right for each athlete. Shared decision-making is a process where a health care professional seeks to make patients informed partners and incorporate their personal goals instead of just dictating treatment.

The authors wrote that their work was not intended as an outline of "disqualification recommendations" but rather "a compendium of clinical considerations" to guide such decisions.

"In the past, there was no shared decision-making about sports eligibility for athletes with heart disease," Kim said. "These athletes were automatically prohibited from participating in sports if almost any cardiac issue was present."

The statement covers more types of athletes than in the past.

One section assesses risk in masters athletes, people age 35 and older, who have coronary disease, atrial fibrillation, enlarged aortas or valve disease. Other sections offer advice for extreme sports athletes, including people who exercise at high altitudes or scuba dive, and address people who want to play competitive sports during pregnancy.

The statement also:

– reinforces the importance of pre-participation cardiac screening for school-age athletes. The AHA's recommended 14-point evaluation includes a physical exam, blood pressure measurement and questions about family and personal health history.

The update says an electrocardiogram, which measures the heart's electrical activity, is a "reasonable" screening for athletes who have no symptoms of heart problems, as long as an expert in athletic EKG interpretation is provided. The authors also emphasize that equitable resources for follow-up evaluations should be available to all athletes included in the screening program.

– offers more guidance for athletes who take blood-thinning medications. The update notes that the higher risk of trauma and bleeding in some activities – such as baseball, tackle football, competitive cycling and outdoor skiing – must be considered.

– revises advice for people with cardiomyopathies, a condition where the heart muscle becomes enlarged, thick or rigid.

Previously, such people were told not to compete in sports. The update rejects a universal mandate and says that under clinical guidance, it may be reasonable for people with some genetic cardiomyopathies to participate in sports.

– updates advice for people with myocarditis, a rare type of heart inflammation.

The previous recommendation for people with myocarditis was that they should not participate in sports for three to six months. Research now suggests that the condition often improves within less than three months, so some athletes with myocarditis might be able to return to play earlier than previously thought.

– offers new advice for young athletes with aortopathy, or abnormalities of the aorta, and the genetic heart rhythm disorder catecholaminergic polymorphic ventricular tachycardia.

Unlike prior statements, the new one doesn't classify sports into specific categories but sees them as dynamic – a continuum of strength and endurance that is athlete-specific. It takes into consideration that not all athletes train the same, not all sports are alike and not all cardiac conditions confer identical risk.

The statement also calls for additional research to answer unresolved questions about athletes and heart risks.

"We know that if you look at sudden cardiac death risk in young athletes, it does appear that young, Black athletes have a higher risk, but we don't know why," Kim said. "We have to look at social disparities because it is a very reasonable hypothesis to believe that disparities play an important role in terms of health outcomes for athletes as they do for people in the general population."