An Athlete’s Journey Through Cardiovascular Screening: Applying a Nonbinary Approach to Sports Participation/Restriction Using Shared Decision-Making

Recent data suggest that the prevalence of conditions associated with sudden cardiac death in Canadian athletes is 0.52%. In an effort to standardize cardiovascular athletic screening, Canada’s first recommendations have been established, emphasizing the nonbinary shared decision-making approach to decisions surrounding management and sports participation of at-risk athletes. Our institution, Queen’s University, recently translated these recommendations into practice, during which a high-risk athlete was encountered through our screening program who otherwise would not have been detected.

Before varsity sports participation, an 18-year-old male rower was required to complete a medical history questionnaire, as well as receive a physical exam and electrocardiogram (ECG) from his family physician or the institution, if the request could not be fulfilled. These screening components were received by an athletic therapist, who conducted a first-pass flagging procedure using a binary approach (normal/abnormal). In this case, the finalized ECG reported a ventricular pre-excitation pattern, whereas the questionnaire and physical exam were both unremarkable. A follow-up appointment with an emergency physician (EMP) confirmed the ECG abnormality and referred the athlete to our sports cardiology clinic. In clinic, the athlete recalled episodic palpitations, one of which occurred during exercise, leading to the diagnosis of Wolff-Parkinson-White syndrome. The ECG abnormality, as well as the controversy surrounding the usefulness and concerns of ECG screening, was discussed with the athlete and his parents by the coaching staff, EMP, cardiologist, and an electrophysiologist. Herein, the shared decision toward partial restriction (continue training at submaximal levels, but not compete) was made, with potential risks explained and discussion clearly documented. To define risk, a stress test was performed, showing gradual disappearance of pre-excitation at around 165 beats per minute. An electrophysiology study was ordered, which indicated a short anterograde refractory period of the pathway; a potentially dangerous condition that could lead to malignant ventricular arrhythmias. The accessory pathway was located laterally on the mitral valve ring, and with appropriate consent obtained, was successfully ablated with no complications. The athlete was cleared to ease into competition with follow-up at 1 month (no restriction). A strong communication link between all care team members provided an extensive discussion regarding this abnormality, interventional options, and its potential effect on participation. Overall, the shared decision-making approach (Fig. 1) contextualizes screening and management for all involved, ensuring an informed decision is made with respect to partial or full restriction. Further case details are shown in the Supplementary Material.