Sports Participation by Athletes With Cardiovascular Disease

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Millions of young people participate in competitive sports, with well-documented physical and psychological benefits.1 Athletes may be diagnosed with cardiovascular disease (CVD) during evaluation of symptoms, routine preparticipation screening, or clinically indicated family screening. When this occurs, decisions about return-to-play (RTP) are difficult, especially in circumstances when risk may exist or be unknown. Historically, expert consensus documents such as the Bethesda Conference Proceedings,2 provided a “yes/no” approach to RTP after a diagnosis of a CVD such as hypertrophic cardiomyopathy (HCM) or long QT syndrome (LQTS). These recommendations were made with a paucity of data, and were predicated on a zero-risk tolerance—that is, only an individual whose risk was no more than the general population should participate in sports.2 This approach inherently fostered paternalistic decision making, in which physicians and institutions made decisions without input from the athlete and family.

With exclusion from sports comes loss of these physical and psychological benefits,1 with documented adverse effects on psychological health. Sports may provide the foundation of an athlete’s identity, as well as provide coping mechanisms. Restriction may lead to loss of the support of the team environment and significant psychological distress.3,4

The approach to the athlete diagnosed with CVD who wishes to RTP has been debated for decades5 (referenced in Shapero et al3 and Martinez et al4). Emerging data and the evolving role of shared decision making (SDM) in medicine have resulted in significant evolution of guidelines and a paradigm shift in approach to these athletes. As such, SDM in RTP, and its ethical and legal bases should be re-addressed in this context.

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