Return‐to‐play in athletes with transvenous and subcutaneous implantable cardiac defibrillator: A meta‐analysis

Rifqi Rizkani Eri; Sania Zahrani; Prasetyo Andriono; Haikal Balweel; Novaro Adeneur Tafriend; Agus Harsoyo

doi:10.1002/joa3.70131

July 2, 2025Journal of ArrhythmiaOpen Access

Return‐to‐play in athletes with transvenous and subcutaneous implantable cardiac defibrillator: A meta‐analysis

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Why the study?

Athletes with ICDs face challenges returning to play over safety, efficacy, and arrhythmic risk, and newly published studies warranted an updated reassessment of transvenous and subcutaneous ICDs.

Does implantable cardioverter-defibrillator use prevent cardiac adverse events in competitive athletes returning to play?

Structured PICO

Does implantable cardioverter-defibrillator use prevent cardiac adverse events in competitive athletes returning to play?

P

Population

6 cohort studies including 1183 competitive athletes with implantable cardioverter-defibrillators (ICDs), predominantly male (>50%). Diagnoses included long QT syndrome (LQTS), hypertrophic cardiomyopathy (HCM), catecholaminergic polymorphic ventricular tachycardia (CPVT), idiopathic ventricular fibrillation (IVF), arrhythmogenic right ventricular cardiomyopathy (ARVC), arrhythmogenic bileaflet mitral valve prolapse syndrome (ABiMVPS), Brugada syndrome (BrS), catecholamine sensitive ventricular tachycardia (CSVT), dilated cardiomyopathy (DCM), valvular heart disease (VHD), coronary artery disease (CAD), congenital heart disease (CHD), and left ventricular non-compaction (LVnc).

I

Intervention

Implantable cardioverter-defibrillators (ICDs), including transvenous and subcutaneous (S-ICD) devices

O

Outcome

Rates of appropriate and inappropriate shocks, shock-related physical injury, cardiac adverse events (during or within 2 h after sports), and sports discontinuationsafety

ICD use in athletes returning to play appears safe with low adverse event rates, supporting tailored return-to-play decisions as recommended by the 2024 HRS guidelines.

Limitations

Absence of EMBASE in search strategy
Notable differences in baseline characteristics (underlying arrhythmias and age distribution)
All included studies were unrandomized
Self-selection in return-to-play decisions

Implication

Supports safe return-to-play decisions for athletes with ICDs; extends pooled observational evidence guiding individualized risk assessment.

Abstract

Background: Arrhythmia in athletes can be career-threatening, and those with implantable cardioverter-defibrillators (ICDs) face significant challenges in returning to play due to concerns about safety, efficacy, and arrhythmic risk. Since the last meta-analysis, additional studies have been published, providing updated data that suggest both transvenous and subcutaneous ICDs (S-ICDs) may allow for a safe return to sports through individualized decision-making. This meta-analysis aimed to reassess the safety and efficacy of ICDs in athletes returning to play. Methods: A systematic review and meta-analysis were conducted following the PRISMA guidelines. Six cohort studies including 1183 athletes with ICDs were analyzed, with five of them on transvenous ICDs and one on S-ICD. Primary outcomes included rates of appropriate and inappropriate shocks, shock-related physical injury, cardiac adverse events, and sports discontinuation. Subgroup and sensitivity analyses were performed to explore heterogeneity. Results: The pooled rate of appropriate shocks was 13% (95% CI 0.11-0.16), while inappropriate shocks occurred in 4% (95% CI 0.02-0.11). No shock-related physical injuries or cardiac adverse events during or shortly after sports were reported (0%). The rate of sports discontinuation was 2%, increasing to4% after sensitivity analysis. Transvenous ICDs showed lower inappropriate shock rates compared to S-ICD. Conclusion: ICD use in athletes returning to play appears safe, with low adverse event rates and minimal sports discontinuation. These findings support tailored return-to-play decisions based on arrhythmia type, ICD programming, and psychological support, aligning with the 2024 HRS Class IIa recommendation.