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Athletes with arrhythmias: Treatment and returning to athletic participation

Mark S Link, MD
Antonio Pelliccia, MD
Section Editors
Scott Manaker, MD, PhD
Peter J Zimetbaum, MD
Deputy Editor
Brian C Downey, MD, FACC


As with the population in general, arrhythmias are not infrequently documented in athletes and can result in significant symptoms and impaired athletic performance. Rarely are arrhythmias fatal; however, sudden cardiac death (SCD) resulting from a malignant ventricular tachyarrhythmia is a devastating event in young and apparently healthy persons.

This topic will discuss the treatment of arrhythmias in athletes, along with the discussion of returning to competition/participation. The clinical manifestations and diagnostic evaluation of athletes with specific arrhythmias or arrhythmia-related syndromes are discussed in detail separately. Additionally, the risk of sudden death in athletes and the approach to screening to prevent sudden death in athletes are discussed elsewhere. (See "Athletes with arrhythmias: Clinical manifestations and diagnostic evaluation" and "Risk of sudden cardiac death in athletes" and "Electrocardiographic abnormalities and conduction disturbances in athletes" and "Screening to prevent sudden cardiac death in athletes".)


Syncope that occurs during exertion suggests a potentially life-threatening arrhythmic etiology (eg, aortic stenosis, hypertrophic cardiomyopathy, ventricular arrhythmia, etc) and should be evaluated urgently. On the other hand, syncope occurring after exertion (eg, during cooling off period) is more likely reflex in origin, similar to the vasovagal faint. Therapies to prevent recurrent syncope in athletes are highly variable depending upon the suspected etiology of the syncope. The diagnostic approach and management of syncope in athletes is similar to that in non-athletes and is discussed in detail separately. (See "Syncope in adults: Clinical manifestations and diagnostic evaluation" and "Syncope in adults: Management".)

Athletes with concerning syncope should have a full evaluation to ascertain the presence of underlying cardiac disease responsible for the syncope. Return to sport is permitted after the cause has been determined and, if necessary, treated. When any underlying cardiac disease has been reasonably excluded, the athlete can safely return to sport without restriction [1]. However, athletes with syncope or presyncope with a high risk of recurrence should not participate in sports where the likelihood of even a momentary loss of consciousness may be hazardous and/or potentially responsible for adverse events (such as scuba diving, rock climbing, automobile racing, etc).


Altered atrioventricular (AV) nodal conduction (eg, first degree AV block and Mobitz type I second degree AV block) can result from increased vagal tone, which is normally seen as an adaptive response to certain types of athletic conditioning, particularly endurance training (table 1). No specific limitations are necessary in this setting as long as the athlete is asymptomatic and the conduction abnormalities improve (ie, disappear) with exertion. However, higher degrees of AV conduction abnormality will require attention prior to participation in athletics.

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Literature review current through: Oct 2017. | This topic last updated: Nov 02, 2017.
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