Sports Cardiology and Shared Decision-Making
Definition
The contemporary clinical framework governing competitive sports participation decisions for athletes with cardiovascular disease (CVD). Since the 2025 AHA/ACC scientific statement, shared decision-making (SDM) is the foundational ethical and clinical principle — replacing the prior paternalistic model of universal sport restriction with individualized, athlete-centred decision-making between clinician and patient.
Key Concepts
Paradigm Shift: From Restriction to SDM
- The 2025 AHA/ACC statement explicitly abandons the historical paternalistic model, which held that athletes "cannot make rational decisions." This is described as both ethically unjustified and clinically unsupported. (sources/competitive-sports-aha-2025, rating: very high)
- SDM framework: Two experts meet — the clinician is expert on medical data and clinical implications; the athlete is expert on personal values, ambitions, and risk tolerance. Both work together toward an informed sports participation decision. (sources/competitive-sports-aha-2025)
- For athletes <18 years: parents/guardians must be included with formal informed consent for the process and outcome. (sources/competitive-sports-aha-2025)
Stepwise SDM Process
- Clinical evaluation: Confirm diagnosis + comprehensive risk stratification + guideline-directed therapy initiation and optimization.
- Education: Provide evidence-based risk/benefit information; convey areas of medical uncertainty clearly.
- Values elicitation: Identify athlete's goals, risk tolerance, life priorities, and relationship to competitive sports.
- Stakeholder engagement: Involve parents, coaches, team physicians, athletic trainers, school/league administrators as appropriate.
- Decision + documentation: Document the SDM process, athlete's understanding, and the agreed outcome.
- Longitudinal surveillance: Regardless of the participation decision — periodic reassessment of clinical course, ongoing SDM, EAP planning. (sources/competitive-sports-aha-2025)
Sports Classification (2025 Update)
- Sports are now presented as a continuum of endurance and strength physiologic demands rather than discrete categories. This mirrors the SDM philosophy of individualized risk rather than categorical restriction. (sources/competitive-sports-aha-2025)
- Endurance component: repetitive contraction of large muscle groups requiring sustained cardiac output increase.
- Strength component: discrete, high-intensity contractions with cyclical blood pressure surges proportional to total muscle mass engaged and percentage of maximal contraction (exercise pressor reflex).
- Sports also classified by bodily collision and impact risk for athletes requiring anticoagulation: low (all anticoagulation acceptable), intermediate (SDM for full anticoagulation), high (risks outweigh benefits for full anticoagulation; aspirin monotherapy acceptable).
Preparticipation Cardiac Evaluation
- History and Physical: Low sensitivity (10–20%) but identifies symptomatic athletes and hereditary CVD. Mandatory component of preparticipation screening. (sources/competitive-sports-aha-2025)
- 12-lead ECG: Increases detection sensitivity to 94%. Reasonable to include if (a) contemporary athletic ECG interpretation expertise is available and (b) downstream resources for secondary evaluation are accessible.
- Racial equity gap: Contemporary ECG criteria carry higher false-positive rates in Black athletes — screening programs must ensure downstream resources and cultural competency to avoid harm. (sources/competitive-sports-aha-2025)
- Advanced testing (cardiac imaging, exercise stress testing, ambulatory monitoring, genetic testing): insufficient data to recommend as routine primary screening in asymptomatic athletes.
- Emergency Action Plan (EAP): Mandatory at all athletic venues. Must include: SCA recognition training, high-quality CPR training, AED access, coordinated medical transport. Annual review and drills required. (sources/competitive-sports-aha-2025)
Terminology Used in Clinical Considerations Tables
| Term | Meaning |
|---|---|
| Can | Evidence or expert consensus: minimal cardiac risk; unrestricted participation without SDM needed |
| Reasonable | Substantive evidence: low and nonprohibitive risk; proceed with SDM |
| Reasonable to consider | Expert consensus + limited evidence: probably low risk; proceed with SDM |
| Can consider | No/limited evidence: may be low risk; SDM required |
| Risks may outweigh benefits | At least moderately elevated risk; integrate in SDM |
| Risks likely outweigh benefits | Markedly elevated risk; integrate in SDM |
SCA Epidemiology in Competitive Athletes
- SCA is the leading medical cause of sudden death in competitive sports. (sources/competitive-sports-aha-2025)
- Among US collegiate athletes (2002–2022): annual SCD incidence 1:63,682. Risk higher in males, Black athletes, and certain sports (basketball, football, soccer). (sources/competitive-sports-aha-2025)
- <35 years: Autopsy-negative sudden unexplained death (not HCM or genetic cardiomyopathies) is now considered the most common cause of SCD in young athletes.
- ≥35 years (masters athletes): Coronary atherosclerosis predominates.
- SCA cannot be completely prevented; EAP deployment after events is not equivalent to "failure" of SDM approach. (sources/competitive-sports-aha-2025)
Sports Cardiology as a Specialty
- Identified as a unique cardiovascular subspecialty with continued growth internationally.
- Most athletes with CVD lack access to high-level sports cardiology expertise — demand outpaces supply.
- Team cardiologist role: critical within the team physician model for cardiac sports eligibility determinations. (sources/competitive-sports-aha-2025)
Diving — the One Recreational Activity Where a Structural Finding Matters
- Recreational scuba diving is not competitive sport, and the evidence base is different. The 2025 AHA sports statement holds that a PFO is not a contraindication to recreational diving and that routine PFO screening is not indicated in divers. (sources/competitive-sports-aha-2025, rating: very high)
- But a PFO raises decompression illness risk approximately fivefold, because a right-to-left shunt lets nitrogen bubbles bypass the pulmonary filter and enter the arterial circulation.
- Closure after a decompression event is not routinely recommended. SCAI 2022 reviewed three observational studies and found recurrent DCI RR 0.31 (0.08–1.13) — non-significant, non-randomised, with an increase in atrial fibrillation and procedural complications in the closure groups. The panel's recommendation is against routine closure, with the alternative being conservative diving measures or cessation. (sources/pfo-jscai-2022, rating: very high)
- Acute decompression illness requires immediate hyperbaric oxygen therapy and referral to a diving medicine specialist — the PFO question follows the acute event, it does not determine its management.
- A diver who chooses closure faces the same post-procedural antiplatelet regimen and the same ~2.4% long-term AF risk as a stroke patient, for an indication where no trial has shown benefit. This is a textbook shared-decision-making scenario in which the clinician's honest position is that the evidence is very weak in both directions.
Contradictions / Open Questions
- Legal framework for SDM untested: No established precedent for clinician liability or protection when SDM leads to athlete sports participation followed by SCA. The Knapp vs. Northwestern (1996) ruling upholds physician exclusion decisions but does not address the SDM framework. Simulation studies suggest SDM may decrease lawsuit likelihood after adverse events, but this has not been prospectively validated in sports cardiology. (sources/competitive-sports-aha-2025)
- Prospective outcomes data gap: The Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) is the first long-term repository of young athletes with CVD but is not yet mature. Most recommendations supporting SDM over universal restriction derive from observational and retrospective data. (sources/competitive-sports-aha-2025)
- ECG racial disparities unresolved: The current ECG interpretation criteria disproportionately flag Black athletes as false-positives. While acknowledged, new validated criteria specific to Black athletes do not yet exist — a call to action without a current solution. (sources/competitive-sports-aha-2025)
- Diving advice sits outside the SDM framework it appears to belong to. The AHA statement says a PFO is not a contraindication to diving and that screening is not indicated, while SCAI suggests against closure after a decompression event and offers behavioural restriction as the alternative — neither position has comparative outcome data. A diver with a shunt and two episodes of decompression illness is therefore managed by two guidelines that both decline to recommend anything, which is the practical limit of evidence-based shared decision-making. (sources/competitive-sports-aha-2025, sources/pfo-jscai-2022)
Connections
- Related to entities/HCM
- Related to entities/DCM
- Related to entities/ARVC
- Related to entities/Long-QT-Syndrome
- Related to entities/CPVT
- Related to entities/Brugada-Syndrome
- Related to entities/Atrial-Fibrillation
- Related to concepts/HCM-Exercise
- Related to concepts/Exercise-Restriction-in-ARVC
- Related to concepts/Sudden-Cardiac-Death
- Related to concepts/Late-Gadolinium-Enhancement