Management of Arrhythmias in Athletes: Atrial Fibrillation, Premature Ventricular Contractions, and Ventricular Tachycardia

Palpitations in athletes: diagnosis, workup and treatment

Palpitations are a common reason for athletes to seek medical care. Although often benign, palpitations may serve as a harbinger for underling cardiac pathology. Given the unique challenges in this population, this review will serve to discuss the basic underlying pathophysiology, which may predispose athletes to palpitations. In addition, we will review the aetiologies, diagnostic evaluation, management and counselling strategies for some of the most common diagnoses seen in athletes.

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Monomorphic Ventricular Arrhythmias in Athletes

Ventricular arrhythmias are challenging to manage in athletes with concern for an elevated risk of sudden cardiac death (SCD) during sports competition. Monomorphic ventricular arrhythmias (MMVA), while often benign in athletes with a structurally normal heart, are also associated with a unique subset of idiopathic and malignant substrates that must be clearly defined. A comprehensive evaluation for structural and/or electrical heart disease is required in order to exclude cardiac conditions that increase risk of SCD with exercise, such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Unique issues for physicians who manage this population include navigating athletes through the decision of whether they can safely continue their chosen sport. In the absence of structural heart disease, therapies such as radiofrequency catheter ablation are very effective for certain arrhythmias and may allow for return to competitive sports participation. In this comprehensive review, we summarise the recommendations for evaluating and managing athletes with MMVA.

Anti-arrhythmic therapy in athletes

The spectrum of arrhythmias that may be encountered in athletes ranges from isolated ectopic beats to ventricular tachycardia, usually in the context of a structurally normal heart. Anti-arrhythmic therapy in these individuals may be particularly challenging because of the young age, the hypervagotonic state, the desire to maintain a high physical performance, the reluctance to take medications and the need to avoid molecules included in the list of prohibited drugs of the World Anti-Doping Agency. Furthermore, the possible serious adverse effects of anti-arrhythmic drugs should be balanced against the benign nature of arrhythmias in patients with no underlying heart disease. The review summarizes the most common arrhythmias of athletes and the possible therapeutic options, including anti-arrhythmic drugs and non-pharmacological interventions. Eligibility criteria according to current guidelines are also addressed.