Sports Safety With Implantable Cardioverter-Defibrillators

Source: Lampert R, Olshansky B, Heidbuchel H, et al. Safety of sports for athletes with implantable cardioverter-defibrillators: results of a prospective, multinational registry. Circulation. 2013; 127(20): 2021– 2030; doi: 10.1161/CIRCULATIONAHA.112.000447Researchers from multiple institutions investigated the risks of sports participation for individuals with implantable cardioverter-defibrillators (ICDs) by analyzing data from a multinational, prospective, observational ICD Sports Safety Registry. Athletes with ICDs (aged 10 to 60 years) were recruited via their physicians and patient internet sites and mailing lists. Data were collected via phone interviews with enrolled participants every 6 months, and medical records were reviewed at 41 North American and 18 European study sites. Patients were queried about shocks received, sequelae, preshock activity, and any change in sports participation, health, or ICD status. The primary outcome was a serious adverse event during or up to 2 hours after sports. Secondary outcomes included shock episodes, moderate injury associated with a shock, and ICD lead damage.Of the 372 participants, 328 were engaged in organized sports, and 44 in high-risk sports. Median age of participants was 33 years (89 participants <20 years of age); 33% were female. Sixty were competitive athletes. The most common diagnoses were long-QT syndrome (n=73), hypertrophic cardiomyopathy (n=63), and arrhythmogenic right ventricular cardiomyopathy (n=55). A pre-ICD history of ventricular arrhythmia was present in 42%. The most common organized sports were running, basketball, and soccer, and the most common high-risk sport was skiing.Over a median 31-month (range, 21–46 months) follow-up, there were no deaths, resuscitated arrests, or arrhythmia-or shock-related injuries during sports. There were 49 shocks in 37 participants (10% of study population) during competition/practice, 39 shocks in 29 participants (8%) during other physical activity, and 33 shocks in 24 participants (6%) at rest. More individuals received shocks during either competition/practice or physical activity than during rest (16% vs 6%; P < .0001), but there was no difference between the proportion receiving a shock during competition/practice and those receiving a shock during other physical activity (10% vs 8%; P = .34). Of the 60 individuals <21 years of age participating in competitive athletics, 17 (28%) experienced a total of 25 shocks. There was no significant difference in the number of appropriate shocks between the competitive subgroup and those not in the competitive subgroup. Overall, 70% of those who received shocks during sports continued to participate. There was no history of lead malfunction in 97% of participants at 5 years (from implantation) and 90% at 10 years.The authors conclude that many athletes with ICDs can engage in vigorous and competitive sports without physical injury or failure to terminate the arrhythmia despite the occurrence of both inappropriate and appropriate shocks.Dr LaBella has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Consensus cardiologist opinion advises against sports participation more strenuous than bowling or golf for patients with ICDs due to concern for device failure, injury from arrhythmia-related syncope or shock, and damage to the ICD. However, the frequency of these adverse events has not been previously investigated. This is the first prospective study to investigate the risks of sports participation for pediatric and adult patients with ICDs. These data suggest that many athletes can safely participate in strenuous and moderate contact sports without risk of physical injury, device damage, or failure of the device to terminate arrhythmia. Overall rates of individuals receiving shocks in this population are similar to those reported for less active, more typical ICD populations.1,2 Lead survival rates were similar to the 85% to 98% lead survival rates at 5 years in more typical ICD populations.3 Finally, and perhaps most importantly, there were no failures of the ICD to convert ventricular arrhythmia.Restricting athletes from sports participation can significantly affect their quality of life. Many adolescents with ICDs and their physicians report that restriction from sports and the resultant feeling of not being normal are among the most important negative aspects of having an ICD.4,5 The fact that the majority of athletes in this study who received shocks during sports chose to continue playing suggests that the benefits of continued sports participation outweighed the negative impact of shocks for these individuals.This study has some limitations. Study participants were self-selected, and thus may not be representative of all ICD patients participating in sports. Most participants had excellent ejection fractions. Shocks were self-reported every 6 months, so may have been underestimated. Although many athletes participated in moderate contact sports (eg, basketball and soccer), very few athletes played collision sports (eg, football, ice hockey). It is possible that injury or ICD damage could be higher in these sports.Despite its limitations, the results of the study do not support a blanket recommendation for all patients with ICDs to avoid competitive sports. The data suggest that for some athletes with ICDs, the benefits of sports participation may outweigh the risks.