Arrhythmias in Athletes: Diagnosis, Risk Assessment, and Treatment Approaches

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EP LAB DIGEST. 2025;25(7):20-21.

Scott A Gall, MBBS, FRCP
Cardiologist and Electrophysiologist, Lancashire Cardiac Centre, Blackpool and Spire Hospital Manchester, UK

Athletes who present with arrhythmias often require specific considerations when evaluating and planning treatment. There are a number of considerations for both the elite/professional athlete as well as highly active individuals, with considerations around career, livelihood, source of income, and mental well-being.

Often following presentation, the main driver for these patients is a return to training and competition, so it is vital that the clinician takes this into account when assessing and planning treatment. Delays in diagnosis and treatment can have severe and lasting impacts on athletes and their careers. The physician has a duty of care to the patient, and an evaluation of ongoing risk following treatment should prompt a discussion with the patient to allow shared decision-making in planning a return to sport.

Arrhythmia Prediction and Prevention
Although not always possible, identifying those at risk of potentially life-threatening arrhythmias is an important consideration. Many sports-governing bodies advocate, and in some cases, mandate the use of cardiovascular screening prior to competition. There are several considerations that need to be taken into account, including available resources, cost implications, and expertise in evaluating results, as high-level athletes may have investigations such as electrocardiograms (ECGs) and echocardiograms that, at first evaluation, appear quite abnormal but may be the result of athletic adaptation. Screening may pick up features such as pre-excitation, in which case, with successful ablation, the specific risk may be eliminated. However, screening may more commonly identify the potential for an underlying condition that may require further investigation and ongoing monitoring and treatment.

Education of athletes may also play an important role in minimizing the risk of sudden cardiac arrest (SCA). This includes knowledge around nutrition and hydration being potentially beneficial in preventing exercise-induced electrolyte abnormalities, risks about the use of performance-enhancing drugs, and risk factors for coronary artery disease (CAD) (an important consideration in athletes over the age of 40).

Screening can identify some of those athletes who may be at risk and others who require further investigation with more thorough investigations, including cardiac computed tomography (CT), cardiac magnetic resonance imaging (MRI), exercise stress testing, and ambulatory monitoring. Genetic testing can be useful in some to confirm a suspected diagnosis, and in some cases, aid with risk stratification. However, it is important to recognize the limitations of genetic testing and the implications of both a positive and negative test for individual athletes and their families. A pre-test discussion with the athlete to discuss these implications is essential to ensure they are aware that a negative test does not fully rule out either risk or a genetic cause. 

Survivors of SCA
Athletes surviving cardiac arrest require prompt in-hospital investigation and treatment, including a thorough history where available, history of chest trauma prior to the event (suggesting commotio cordis), and ECG strips from external defibrillators. Thorough investigation is vital to establish the likely underlying cause and inform future treatment and risk reduction. Occasionally, in the absence of positive investigations, wide panel genetic testing can be performed. Despite thorough investigations, some cardiac arrests do remain unexplained, creating a challenge in assessment of future risk.

Diagnosis 
Athletes who have abnormal initial screening (with or without symptoms), who have survived cardiac arrest or present with symptoms suggestive of arrhythmia (with or without previous screening), require further evaluation and investigation. Again, a thorough history and examination is essential to aid in diagnosis and guide appropriate investigations. As a minimum, all patients should have a 12-lead ECG as a starting point, which may help guide further investigation. It is important that athletes are assessed by a clinician who has expertise in the diagnosis and management of arrhythmias in athletes. It is vital that the clinician also understands the likely demands of ongoing sports participation. In addition, discussion with the athlete, coaches, family, etc, is equally important in discussing any treatment and future risk.

An ECG suggestive of an ST elevation myocardial infarction requires urgent coronary angiography and revascularization if appropriate. ECGs at the time of symptoms may reveal arrhythmias such as atrial fibrillation (AF), atrial flutter, supraventricular tachycardia (SVT), or ectopics. ECGs may also show evidence of pre-excitation suggestive of Wolff-Parkinson-White (WPW) syndrome, changes suggestive of Brugada syndrome, and long or short QT syndrome. ECGs may also show changes suggestive of hypertrophic cardiomyopathy or arrhythmogenic right ventricular cardiomyopathy (ARVC).

An echocardiogram may help with diagnosis in patients with hypertrophic cardiomyopathy, dilated cardiomyopathy, and some cases of arrhythmogenic ventricular cardiomyopathy/ARVC and anomalous origin of coronary arteries.

Further imaging with cardiac MRI is useful in patients with myocarditis, arrhythmogenic ventricular cardiomyopathy, hypertrophic cardiomyopathy, and conditions such as sarcoidosis.

Imaging of coronary arteries with either CT or conventional angiography can be useful in identifying CAD or anomalous origins of coronary arteries, and evaluating for a potential malignant course predisposing to life-threatening arrhythmias.

Ambulatory ECG monitoring can be useful in identifying paroxysmal arrhythmias such as SVT (eg, atrioventricular nodal re-entrant tachycardia [AVNRT] and atrioventricular re-entrant tachycardia [AVRT] and AF. It is also useful in identifying ectopics, including ectopic burden, and may suggest catecholaminergic polymorphic ventricular tachycardia (CPVT).

Wearable technology may be useful for athletes with very intermittent arrhythmias, and as technology evolves, earlier identification of arrhythmias such as AF is likely to become easier. It is important that any ECGs are evaluated for appropriate diagnostic quality and by a clinician expert in evaluating arrhythmias prior to definitive diagnosis. 

An exercise stress test may be useful in the identification of CPVT and long QT syndrome. A catecholamine challenge can also be useful, although both may have limitations.

Sometimes in the absence of other positive results, a diagnostic electrophysiological (EP) study can be useful, especially in the diagnosis of SVT (AVNRT and AVRT). 

Treatment of Arrhythmias in Athletes
SCA requires immediate resuscitation and defibrillation prior to transfer to hospital for further investigation and longer term treatment. Unless a clear reversible cause is identified, these individuals should be assessed for an implantable cardioverter-defibrillator (ICD) as an inpatient if indicated based on their investigations and subsequent diagnosis. These patients may also require medication to reduce future risk of arrhythmias and potential ICD therapies. Both ICD and medication may have a significant impact on the athlete’s ability to return to their chosen sport and/or previous level of performance. Some athletes with ICDs have returned to high-level competitive sport after appropriate evaluation and discussion of risk. This is dependent on the underlying diagnosis and evaluation often with exercise testing followed by a discussion regarding future risk. Some underlying conditions, such as arrhythmogenic cardiomyopathy/ARVC, may be worsened with vigorous exercise, and ongoing participation in competitive sport may not be recommended. This creates a challenge for the athlete, who may be faced with a loss of career and earning potential, and may result in significant psychological challenge or mental health issues that should be considered at the outset.

Most other arrhythmias may not present as an emergency and may require a period of elective outpatient investigation prior to treatment planning. Depending on symptoms and the results of initial assessment and investigations, it may be necessary to advise the athlete against participating in sport until a diagnosis has been made. If this is the case, a clear discussion regarding likely timeframes and next steps for investigation, etc, is essential in order to manage expectations.

The treatment of SVT, including WPW, is usually with catheter ablation of the arrhythmia. There are several considerations from an athlete’s perspective that are important. The risk of conduction system injury and potential pacemaker implantation is one such important factor in athletes. Depending on the location of any accessory pathway, this can help inform potential risk, and although the risks can be minimized with the use of modern technologies, the risk can never be completely negated. In the presence of a high-risk pathway in WPW syndrome, this is often a likely acceptable risk; however, for athletes with very infrequent AVNRT that does not impact athletic performance and causes minimal symptoms, even a very small risk may not be acceptable and needs to be considered when planning treatment. 

Treating AF
The treatment of AF (and other atrial arrhythmias) is one of the more complex considerations in patients who are athletes. While exercise tends to reduce the risk of cardiac pathologies, there is evidence that the risk of AF is increased in certain populations, even in the absence of other AF risk factors. The risk of AF is increased in athletes participating in ultra endurance exercise, especially in men over 35.

While some patients with AF can be managed with medication, athletes often do not tolerate this treatment approach, with many medications reducing heart rate and potentially limiting athletic performance. It is also important to be aware of any medications that may be prohibited in specific sports.

Athletes are more likely to benefit from catheter ablation of AF, and it is reasonable to offer this as first-line therapy, especially if medication has been tried or the athlete does not wish or is unable to take regular medication. The small, short-term risk of the invasive procedure needs to be considered and expectations need to be managed with regards to outcomes. Early treatment is considered to be more successful, and with modern technologies, the chances of first-time success are improved; however, discussion regarding the potential for recurrence in the future is important as well as the potential for further procedures. It is important that any other risk factors for AF are addressed, such as hypertension, alcohol intake (sometimes excessive in amateur athletes), and the potential presence of obstructive sleep apnea (which may be increased in power sports, with high muscle mass around the neck).

Another consideration in the treatment of AF is the role of anticoagulation. In athletes, often the longer term risk of stroke is low and long-term anticoagulants may not be mandated; however, if a patient is undergoing AF ablation, it is important that they are aware of the need for at least a period of anticoagulation. This may have significant implications in contact sports or sports with increased risk of injury. 

Conclusion
Athletes who present with an arrhythmia require additional consideration with regards to investigation, treatment, and follow-up. Shared decision-making is vital throughout the process to understand appropriate risks and allow the athlete to make an informed decision regarding their care and ongoing athletic participation. 

This is a complex area of cardiology, and it is important that the clinician is aware of all considerations with regards to the individual athlete. This may well involve overlap between multiple subspecialties within cardiology and sports medicine to provide appropriate considered care. As this is a specialist area with many variables, this article is designed to give an overview of this growing area of cardiology and is not to be considered all inclusive. There are national and international guidelines that are helpful as an initial reference point in the management of these patients and are much more detailed, including the recently published statement from the American Heart Association and American College of Cardiology.¹ The evidence base for arrhythmias in athletes is evolving, but there are still gaps and uncertainties. With ongoing research and advances in treatments and technology, this evolving field will allow improved understanding and consistency in the treatment of athletes with arrhythmias. 

Disclosure: Dr Gall has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and report no conflicts of interest regarding the content herein.

Reference
1.    Kim JH, Baggish AL, Levine BD, et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: a scientific statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2025;85(10):1059-1108. doi:10.1016/j.jacc.2024.12.025