Long-term risk assessment in athletes with complex ventricular arrhythmias

Abstract Background Ventricular arrhythmias (VAs) are a major concern in athletes. We sought to determine the prognostic role of non-invasive and invasive assessments in athletes with complex VAs. Methods Two-hundred-fifteen athletes (83% male; 28 [19-43] years; 162 [75%] competitive athletes) with complex VAs were included in a multicenter cohort study and categorized based on VA ECG morphology into common (n=110) and uncommon (n=105) VA groups. Each athlete underwent a comprehensive diagnostic workup, including cardiac magnetic resonance (CMR) in 94% (n=202) and electrophysiology study (EPS)/electroanatomical mapping (EAM) in 88% (n=190). The primary endpoint was the occurrence of sudden death or sustained VAs during long-term follow-up. Results athletes with uncommon VA morphology had higher rates of abnormal findings at multimodality assessment, and more final diagnoses of structural heart disease. Over a median follow-up of 6.2 (4.4-8.1) years, 16 (7%) athletes experienced a primary outcome event, including one sudden death. Interestingly, no events occurred in athletes with common morphology VAs without sustained VAs at baseline. In univariable Cox models (Figure), factors associated with the primary endpoint included uncommon VA morphology (p=0.004), sustained VAs at presentation (p<0.001), syncope (p=0.005), abnormal ECG findings (p=0.003), VAs induction/persistence during exercise testing (p=0.021), late gadolinium enhancement (LGE; p=0.006), electroanatomical scar regions (p=0.003), late potentials at EAM (p<0.001), and sustained VA inducibility by EPS (p<0.001). EPS inducibility retained significant association in multivariable analysis (aHR,7.20; p=0.008). A survival tree model based on VA type, VA morphology, LGE, VA response to exercise testing, and EAM allowed risk stratification, identifying subgroups of athletes without primary outcome events during follow-up (Figure). Among 162 competitive athletes, 108 (67%) regained eligibility at 3 months, but only 44 (27%) continued long-term. Factors linked to uninterrupted sports participation included younger age(p=0.032), professional athlete status(p=0.006), and absence of LGE(p=0.029). Conclusion a comprehensive diagnostic assessment integrating clinical/ECG and imaging findings, along with the selective use of invasive electrophysiology assessments, may help refine the prognostic evaluation of athletes with complex VAs.Figure.Main study findings.