Sports Clearance Decision Guide¶

Pre-Participation Evaluation¶

flowchart TD
    A[Athlete Presenting for<br/>Sports Clearance] --> B{Any Symptoms?}

    B -->|Yes - Syncope, chest pain,<br/>palpitations, dyspnea| C[Full Cardiac Evaluation<br/>Before Clearance]
    B -->|No| D{Family History<br/>Red Flags?}

    D -->|Yes - SCD <50,<br/>known HCM/LQTS| C
    D -->|No| E{Physical Exam<br/>Abnormalities?}

    E -->|Yes - Murmur increasing with<br/>Valsalva, Marfanoid features| C
    E -->|No| F{ECG Abnormal?<br/>if performed}

    F -->|Yes - T inversions,<br/>QTc prolonged, WPW| C
    F -->|No| G[Standard Clearance]

    C --> H[Echo ± Additional Testing]
    H --> I{Diagnosis?}

    I -->|Normal| G
    I -->|Condition Identified| J[Condition-Specific<br/>Clearance Decision]

📋 Text Version (if diagram doesn't render)

**Sports Clearance Pre-Participation Evaluation** 1. **Any Symptoms?** (syncope, chest pain, palpitations, dyspnea) - YES → Full cardiac evaluation before clearance 2. **Family History Red Flags?** (SCD <50, known HCM/LQTS) - YES → Full cardiac evaluation 3. **Physical Exam Abnormalities?** (murmur increasing with Valsalva, Marfanoid features) - YES → Full cardiac evaluation 4. **ECG Abnormal?** (T inversions, prolonged QTc, WPW) - YES → Full cardiac evaluation 5. **All NO** → Standard clearance 6. **If cardiac evaluation needed:** Echo ± additional testing → Normal? → Clearance; Condition identified? → Condition-specific decision

Condition-Specific Recommendations (2025 Guidelines)¶

Conditions Using Shared Decision-Making¶

Condition	May Participate	Requirements
LQTS	Yes - SDM	Beta-blocker, AED access, no competitive swimming
HCM (lower risk)	Yes - SDM	Risk stratification, ICD discussion
WPW (asymptomatic)	Yes - SDM	Risk stratification, ablation option
Myocarditis (recovered)	Yes - after 3-6 months	Normal echo, Holter, stress test
AAORCA (negative stress)	Yes - SDM	Documented negative stress testing

Conditions With Stronger Restrictions¶

Condition	Recommendation
AAOLCA (any)	Restrict until repaired
CPVT	Restrict from competitive sports
HCM (high-risk features)	Restrict - discuss ICD
Marfan with aortic dilation	Restrict from contact/burst activities
Eisenmenger syndrome	No competitive sports
Severe aortic stenosis	Restrict from competitive sports

Return to Play After Events¶

Condition	Minimum Restriction
Myocarditis	3-6 months
Pericarditis	Until asymptomatic + normal CRP
Myopericarditis	3-6 months + normal workup
MIS-C (cardiac involvement)	3-6 months based on severity
COVID-19 (no cardiac)	2 weeks minimum
After AAOCA repair	3 months + normal stress test
After ablation	Usually 1-2 weeks

Shared Decision-Making Framework¶

Required Elements¶

Full disclosure of risks
Sudden death statistics for condition
Uncertainty in individual risk
Comprehensive evaluation
All appropriate testing completed
Risk stratification performed
Risk mitigation discussion
AED availability
Emergency action plan
Treatment adherence (medications)
Documentation
Informed consent
Shared decision process documented
Family/athlete involvement
Both must understand and accept risk
Coach/athletic trainer awareness

Testing for Return to Play¶

Standard Clearance Testing¶

Echo: Normal function, no residual abnormality
Holter: No significant arrhythmias
Exercise stress test: No exercise-induced arrhythmias, appropriate BP response

Condition-Specific Testing¶

Condition	Additional Testing
Myocarditis	CMR (no active inflammation, minimal LGE)
AAOCA post-repair	Stress perfusion imaging
Channelopathy	Genetic counseling, exercise stress test
HCM	Risk score calculation

Red Flags That Preclude Clearance¶

Unexplained exertional syncope (until evaluated)
Symptoms during exercise not explained
Significant structural heart disease not yet evaluated
Active myocarditis or pericarditis
Severe outflow obstruction
Uncontrolled arrhythmias
Recent cardiac surgery (timing varies)