Criteria for eligibility and disqualification from organized competitive sports health and safety of young athletes.

Preamble, Principles, and General Considerations.

Young athletes may be subject to Cardiac checks to confirm their heart’s fitness and participation.

Young trained athletes with underlying cardiovascular abnormalities are at an increased risk for sudden cardiac death.

Considerations such as protection of the athlete’s health and avoidance of an unreasonable risks for sudden death during competitive athletics are stressed when addressing medical eligibility versus disqualification decisions, which have become increasingly complex.

This is nothing new, the guidelines are as old as 1985 and have been practices and publicised across the cardiac physicians for last 30 years, were driven by the tenet that young trained athletes with underlying cardiovascular abnormalities are likely at some increase in risk for sudden cardiac death (usually on the athletic field) compared to nonathletes or competitive athletes without cardiovascular disease.

Causes of Sudden Death in Athletes

• The cardiovascular causes of sudden death in young athletes have been well documented in forensic databases. These deaths occur in both sexes (although more commonly in males, defined by a likelihood ratio by 9:1); in minorities, prominently including African-Americans and in a wide range of individual and team sports. In the United States, among people <35 years old, genetic heart diseases predominate, with hypertrophic cardiomyopathy being the most common, accounting for at least one-third of the mortality in autopsy-based athlete study populations.

• Congenital coronary anomalies (usually those of wrong sinus origin) are second in frequency, occurring in ≈15% to 20% of cases. Other less common diseases, each responsible for ≈5% or fewer of these sudden deaths, include myocarditis, aortic valve stenosis, aortic dissection/rupture (including cases of the Marfan phenotype), atherosclerotic coronary artery disease, ion channelopathies, and arrhythmogenic right ventricular cardiomyopathy.

• In addition, commotio cordis (ie, sudden death caused by blunt, nonpenetrating chest blows, associated with structurally normal hearts) is more common as a cause of sudden death in young athletes than many of the aforementioned structural cardiovascular diseases.

Regional variations in the causes of sudden death may exist.

Recent Guidelines have been made available post Bethesda Conference 36. Nevertheless, numerous “gray areas” persist, for which the assessment of safe versus nonsafe sports participation continues to be uncertain from a medical and scientific perspective, with absolute certainty difficult to achieve for many cardiovascular issues.

Excerpts from the conclusion section of the white paper states, “Clinicians should also recognize that medical eligibility versus disqualification decisions have become increasingly complex. Also, these decisions may be fraught with potential legal liability risks. Therefore, it is unwise to be unduly influenced by the libertarian (free will) desires of athletes (with an important cardiovascular abnormality) willing to assume medically unreasonable risks to participate in a sport, nor by the managing clinician’s personal willingness to comply with the desires of the individual athlete-patient. Finally, it is important to recognize that third-party interests (eg, on behalf of high schools, colleges, or professional clubs) unavoidably contribute to the complexity in the decision-making process, but these should not outweigh the paramount concern for the athlete’s health and safety when making medical eligibility recommendations.

Original Article AHA Circulation network, Unites States of America