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Eligibility and Disqualification Recommendations for Competitive JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. - ,NO.- ,2015 ª 2015 BY THE AMERICAN HEART ASSOCIATION, INC. AND ISSN 0735-1097/$36.00 THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION http://dx.doi.org/10.1016/j.jacc.2015.09.032 PUBLISHED BY ELSEVIER INC. AHA/ACC SCIENTIFIC STATEMENT Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations A Scientific Statement From the American Heart Association and American College of Cardiology Barry J. Maron, MD, FACC, Co-Chair* Douglas P. Zipes, MD, FAHA, MACC, Richard J. Kovacs, MD, FAHA, FACC, Co-Chair* Co-Chair* This document addresses medical issues related to to the practicing community for clinical decision trained athletes with cardiovascular abnormalities. making. The ultimate goal is prevention of sudden The objective is to present, in a readily useable death in the young, although it is also important not format, consensus recommendations and guidelines to unfairly or unnecessarily remove people from a principally addressing criteria for eligibility and healthy athletic lifestyle or competitive sports (that disqualification from organized competitive sports for may be physiologically and psychologically inter- the purpose of ensuring the health and safety of twined with good quality of life and medical well- young athletes. Recognizing certain medical risks being) because of fear of litigation. It is our goal that imposed on athletes with cardiovascular disease, it the recommendations in this document, together is our aspiration that the recommendations that with sound clinical judgment, will lead to a healthier, constitute this document will serve as a useful guide safer playing field for young competitive athletes. *On behalf of the American Heart Association Electrocardiography and The American College of Cardiology requests that this document be Arrhythmias Committee of the Council on Clinical Cardiology, Council on cited as follows: Maron BJ, Zipes DP, Kovacs RJ; on behalf of the American Cardiovascular Disease in the Young, Council on Cardiovascular and Heart Association Electrocardiography and Arrhythmias Committee of the Stroke Nursing, Council on Functional Genomics and Translational Council on Clinical Cardiology, Council on Cardiovascular Disease in the Biology, and the American College of Cardiology. Young, Council on Cardiovascular and Stroke Nursing, Council on Func- The American Heart Association and the American College of Car- tional Genomics and Translational Biology, and the American College of diology make every effort to avoid any actual or potential conflicts of Cardiology. Eligibility and disqualification recommendations for interest that may arise as a result of an outside relationship or a competitive athletes with cardiovascular abnormalities: preamble, prin- personal, professional, or business interest of a member of the writing ciples, and general considerations: a scientific statement from the panel. Specifically, all members of the writing group are required to American Heart Association and American College of Cardiology. J Am complete and submit a Disclosure Questionnaire showing all such Coll Cardiol 2015;xx:–. relationships that might be perceived as real or potential conflicts of This article has been copublished in Circulation. interest. The Task Force reports for these proceedings are available Copies: This document is available on the World Wide Web sites of the online at www.onlinejacc.org (J Am Coll Cardiol 2015;XX:000–000; American Heart Association (http://my.americanheart.org) and the 000–000; 000–000; 000–000; 000–000; 000–000; 000–000; 000–000; American College of Cardiology (www.acc.org). For copies of this docu- 000–000; 000–000; 000–000; 000–000; 000–000; 000–000; and ment, please contact Elsevier Inc. Reprint Department via fax (212-633- 000–000). 3820) or e-mail ([email protected]). This statement was approved by the American Heart Association Permissions: Multiple copies, modification, alteration, enhancement, Science Advisory and Coordinating Committee on June 24, 2015, and and/or distribution of this document are not permitted without the ex- the American Heart Association Executive Committee on July 22, 2015, press permission of the American College of Cardiology. Requests may be and by the American College of Cardiology Board of Trustees and completed online via the Elsevier site (http://www.elsevier.com/about/ Executive Committee on June 3, 2015. policies/author-agreement/obtaining-permission). PGL 5.4.0 DTD JAC21830_proof 15 October 2015 3:44 am ce 2 Maron et al. JACC VOL. - ,NO.- ,2015 Competitive Athletes: Preamble - ,2015:- – - HISTORICAL CONTEXT publication of the 36th Bethesda Conference (3),new conditions associated with sudden death in the young There have been 3 prior documents, all sponsored by have been recognized, and knowledge of the responsible the American College of Cardiology (ACC) (1–3),that diseases and inherent risks of sudden cardiac death in the addressed eligibility and disqualification criteria for com- young has evolved (4–8).Asaresult,someselectedareas petitive athletes with cardiovascular diseases: Bethesda of the 36th Bethesda Conference may have become Conferences 16 (1985), 26 (1994), and 36 (2005), published obsolete, and novel issues not previously addressed, have and used over a 30-year period. Each of the 3 initiatives emerged. Third, an increasing number of adults with (and the present American Heart Association (AHA)/ACC congenital heart disease and cardiomyopathies are now scientific statement) were driven by the tenet that young being recognized (often with surgical palliation or trained athletes with underlying cardiovascular abnor- correction) who wish to engage in competitive athletics malities are likely at some increase in risk for sudden and require contemporary recommendations. In addition, cardiac death (usually on the athletic field) compared to the increasing penetration into cardiovascular practice of nonathletes or competitive athletes without cardiovas- implantable devices (e.g., pacemakers and cardioverter- cular disease (4–8). defibrillators) has created greater numbers of physically All 3 Bethesda Conferences and the present derived active young people with genetic heart diseases who have AHA/ACC document provide expert consensus recom- had devices implanted and who may aspire to participa- mendations. These insights use 1) the experience and tion in competitive athletics. Recently, there has been expertise of the panelists (i.e., individual and collective greater deployment of automatic external defibrillators at judgments, using the “art of medicine”) and 2) available athletic events in recognition of sudden death risk in scientific evidence that estimates the medical risk in young athletes. Finally, the practicing cardiovascular athletes with underlying acquired, genetic, and congen- community deserves and expects the most up-to-date ital heart abnormalities imposed by the unique lifestyle of information on which to make important clinical de- engagement in competitive sports. cisions regarding eligibility versus disqualification of These insights can be applied to decision making for competitive athletes. temporary or permanent disqualification versus eligibility of athletes with probable or conclusive evidence of car- DEFINITIONS diovascular disease; however, the scientificdatasup- porting many of the recommendations in this document As in the 3 Bethesda Conferences (1–3),thebasicdefini- are unavoidably limited, as evidenced by the frequent tion of a competitive athlete remains unchanged: One assignment of a Level of Evidence C. Nevertheless, each who participates in an organized team or individual sport of the 3 prior Bethesda Conferences has served the prac- that requires regular competition against others as a ticing community well, offering clinicians a consensus central component, places a high premium on excellence reference document that is potentially helpful in re- and achievement, and requires some form of systematic solving predictably difficult clinical dilemmas. It is our (and usually intense) training. Therefore, organized expectation that the present conservative AHA/ACC competitive sports are regarded as a distinctive activity scientific statement will follow in that tradition. The final and lifestyle. An important principle concerns whether document was approved by all participants and assigned competitive athletes with either known or unsuspected outside reviewers. cardiovascular disease can be expected to properly judge when it is prudent to terminate physical exertion. Indeed, IMPETUS FOR THE PRESENT DOCUMENT the unique pressures of organized sports do not allow athletes to exert strict individual control over their level There are a number of factors that support the decision to of exertion or reliably discern when cardiac-related update the 36th Bethesda Conference here (3).First, symptomsorwarningsignsoccurthatshoulddictate sudden cardiac deaths in young healthy athletes remain termination of the activity. tragic and counterintuitive events, subject to persistently Furthermore, it is emphasized that these AHA/ACC high public visibility, emotion, and media scrutiny, with recommendations should not be regarded as a general potential legal liability considerations. Therefore, a strong overriding injunction against all forms of exercise. impetus remains to identify high-risk athletes to reduce Notably, this document is concerned only with organized their
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