Supraventricular tachycardia (SVT) is a broad term that encompasses various forms of arrhythmias, which are initiated and maintained by atrial and atrioventricular nodal tissue.1 The mechanism of this condition can be due to reentry (where additional conductive cardiac tissue creates a secondary pathway for an action potential), triggered activity, or abnormal automaticity.2,3 The tachyarrhythmias stem from the sinus node, atrium, atrial flutter, atrioventricular junction, or accessory atrioventricular pathways.3 Depending on the type of SVT, the atrial rate can reach upward of 250 to 600 beats per minute (bpm).3 Supraventricular tachycardia often commences and terminates suddenly.1
Atrial flutter, occurring when an ectopic focus in the atria gives rise to a rapid series of atrial depolarization, was experienced by the athlete discussed in this case review. Naccarelli et al4 found a prevalence of 1.12% atrial fibrillation and atrial flutter for the 21 648 682 individuals aged ⩾20 years in the MarketScan Commercial Claims and Encounters database from Thomas Reuters (Cambridge, Massachusetts). The prevalence for atrial flutter was 0.02%. Of the group with atrial flutter, 58.4% were aged ⩾65 years (mean age, 67.6±14.4 years).4 The authors estimated 0.07 million individuals in the United States have atrial flutter, compared with an estimated 3.03 million individuals with atrial fibrillation and 0.19 million individuals with both atrial flutter and atrial fibrillation.4 Emergency department visits for SVT have been shown to be highest for adults >65 years and higher for women than for men.5
According to the 36th Bethesda Conference,2 a diagnosis of atrial flutter does not automatically disqualify an athlete from competitive sport participation, although there are contingencies. Full clearance to participate is granted to asymptomatic athletes if episodes of atrial flutter are transient, lasting <10 seconds, and do not increased with exercise.2 In the absence of structural heart disease, the athlete should be prohibited from full competitive participation until atrial flutter has not occurred for 2 to 3 months, with or without pharmacological intervention.2 Should atrial flutter occur in conjunction with structural heart disease, inclusive of the repaired ventricular septal defect (VSD) present in our case, the athlete may participate only in sports low in both static and dynamic intensity components, such as golf or cricket. Atrial flutter must first be absent for 2 to 4 weeks for full participation to be granted.2,6
The nature of action sports differs considerably from that of traditional sports. Action sports athletes often do not have easy and affordable access to comprehensive health care services in the same manner as do professional athletes in traditional sports. As a result, a complete medical history may not be available or key sport-specific information may be overlooked when clearance to fully participate is granted. Moreover, current participation guidelines for athletes with SVT do not address the risks when symptoms and treatment side effects are coupled with sports that require the performance of difficult, and often dangerous, tricks.2 Sports medicine clinicians involved in the care of such an athlete must consider SVT within the context of an athlete’s specific sport before a prudent participation decision can be determined.
BMX is classified as an action sport and consists of performing tricks on a bicycle. The bicycle is smaller in size than that of a standard road or mountain bicycle and may lack brakes, per the rider’s preference. Various disciplines comprise the sport. The athlete described in this case review participated in the park and vert disciplines. For park, athletes perform tricks on and over ramps of various sizes and shapes. For vert, a name that indicates the vertical nature of the ramp’s walls, a single, U-shaped half-pipe is used to perform primarily aerial tricks; athletes can reach heights of 20 feet.
In addition to muscular strength and cardiovascular fitness, the freestyle BMX riders appear to have a need for high levels of motor control, kinesthetic awareness, proprioception, balance, and aerial awareness to properly and safely execute tricks, although there are no published studies to confirm this. Cardiac symptoms or medication side effects can greatly impair these necessary components.7,8 If the above components are compromised, an athlete may find himself unable to not only perform tricks at the desired skill level, but also avoid serious injury. This issue should be addressed by the athlete’s physician(s) when determining treatment interventions and full participation status.
A decrease in cardiac output and blood pressure secondary to the use of a beta blocker may hinder an athlete’s ability to meet the physiological demands of freestyle BMX.7,8 Consequently, despite an athlete’s current levels of strength and fitness, fatigue, resulting from a beta blocker, can limit performance.7,8 A BMX rider must be able to pump (ie, use a squatting mechanism to ride down and up ramps) to gain the speed, momentum, and height necessary to execute an ensuing trick. Fatigue can limit an athlete’s ability to effectively pump, thus increasing the difficulty experienced when performing tricks. In addition, the athlete may experience dizziness or lightheadedness while riding. Due to the impaired ability to locate his body in space or to hold his body and bicycle in a particular position, the risk for falls and injury increases.
A dearth of information exists about the specific physiological demands associated with participation in freestyle BMX. The study by Moreland9 of 7 elite freestyle BMX riders proposed a physiological profile by administration of a battery of fitness assessments. The athletes were found to have fitness characteristics similar to elite athletes in traditional sports such as soccer and baseball. The VO2 max for this group was 43.48±6.10 mL/kg/min, and Wingate peak power was 802.50±91.44 watts. It was determined that the sport of freestyle BMX requires “high flexibility, power, strength, anaerobic capacity, and aerobic capacity” for successful performance.9
Atrial fibrillation and atrial flutter are the most common arrhythmias occurring in athletes.10 They are often associated with endurance sports11–14 and are believed to result from increased resting vagal tone or from increased sympathetic tone with exercise.10,13,15 Although freestyle BMX riders participate in training sessions that can last more than 4 hours, they typically ride in intervals, known as runs, which are shorter than 30 seconds in duration. They also have long rest periods between runs. Atrial flutter can occur secondary to exercise-induced fatigue.16
This 26-year-old man’s pediatric cardiac medical history is extensive. It includes congestive heart failure and cardiomegaly from a VSD. The VSD was surgically repaired at age 18 months. Following the repair, he was without cardiac incident until age 19 years. He began a BMX career at age 16 years and entered his first professional competition at age 21 years.
In September 2001, the initial onset of SVT occurred while the patient swam leisurely in a pool. A trigger could not be identified. The emergency department’s evaluation revealed a resting heart rate of 220 bpm, and the electrocardiogram (ECG) demonstrated atrial flutter. The SVT was terminated by administration of intravenous adenosine. On referral to a cardiologist, an electrophysiology study and subsequent extensive catheter ablation were performed, and the athlete remained SVT free for more than 3 years. In spring 2005, he began full-time employment as a stone mason.
In April 2005, at age 23 years, the SVT reemerged while the patient participated in freestyle BMX. He was able to terminate the rhythm without medical intervention by “taking a deep breath.” However, over the course of the ensuing 5 months, the efficacy of this method declined. In addition, the frequency and duration of the SVT episodes increased, but occurred only when he participated in freestyle BMX. In September 2005, he reported to the local emergency department after experiencing SVT for 1 hour. His heart rate ranged between 216 and 225 bpm, and his blood pressure was 99/73 mmHg. Placing the patient in the Trendelenburg position with a Valsalva maneuver and coughing were successful in achieving a sinus rhythm after 2 attempts. He was given a low-dose oral beta blocker (atenolol 25 mg), which began a once-daily regimen over the next 2 years.
During these 2 years, SVT occurred up to several times per month. The SVT occurred only while riding, which was not appreciated by the emergency department, primary care, or cardiac physicians. The emergency department’s administration of various combinations of intravenous beta blockers, calcium channel blockers, and antiarrhythmics were often unsuccessful. Subsequently, the patient began to resist medical attention. The SVT episodes continued to resolve spontaneously, but each lasted up to 2 hours. Due to the patient’s complexity, he was referred to a cardiologist at a major medical center. In May 2007, an electrophysiology study and second cardiac ablation were performed. The patient recovered without incident, and daily atenolol was discontinued. He was cleared to return to work and riding 12 days after ablation.
Twenty days after ablation, the patient presented to the local emergency department with SVT, which began 1 hour earlier while riding. He reported experiencing numerous instances of palpitations since the ablation was performed. Ultimately, he converted to an irregular sinus rhythm following intravenous administration of 3 medications: 6 mg adenosine followed by 12 mg adenosine, 5 mg metoporol, and 20 mg diltiazem. Daily 25 mg atenolol was resumed, and he returned to his cardiologist.
A graded treadmill test was unable to elicit SVT. The patient’s cardiologist was reticent to perform a third ablation and recommended continuing the atenolol regimen, despite the atenolol-induced symptoms. After 6 weeks, the cardiologist cleared the patient to compete in a professional vert competition. At the competition, completion of a medical history was not enforced; consequently, the event’s medical staff was unaware of the history of SVT. Secondary to complaints of dizziness, the athlete fell 14 feet and sustained injuries, which removed him from the competition.
Over the next 5 months, the patient experienced increasingly frequent SVT events. He also complained of fatigue, lightheadedness, and dizziness while riding, independent of SVT. In November 2007, the cardiologist added a low-dose antiarrhythmic (flecainide 50 mg) twice daily and offered no additional treatment options or alternatives. The flecainide regimen did not reduce his symptoms while riding. In December 2007, the patient was found to have a heart rate of 60 bpm immediately after running three 100-meter sprints, which he stopped secondary to complaints of near syncope. The patient called the cardiologist and was simply told to follow up in 1 year.
By May 2008, SVT occurred nearly every time the patient rode his bicycle. Conservative methods to cease the SVT rhythm, such as performing a Valsalva maneuver, were ineffective. The amount of time for which he endured SVT before seeking medical attention continued to increase. The beta blocker and anti-arrhythmic medications’ side effects impaired his ability to ride his bicycle and work safely.
Between May 2007 and June 2008, the patient endured 4 serious falls while performing relatively easy tricks, requiring physician care. He attributed the falls to symptoms of dizziness and fatigue, which had been overlooked by treating physicians under the guise that falls and injuries are inevitable in freestyle BMX. A referral to an electrophysiologist (a cardiologist with expertise in cardiac disorders that are electrical in nature) is warranted if SVT occurs with syncope or severe symptoms, if the patient experiences drug resistance or intolerance, or if the patient prefers to not undergo drug therapy.1 The patient’s chance conversation with an athletic trainer led to referral to an electrophysiologist at a different major medical center.
The electrophysiologist’s initial evaluation included an extensive history, a full systems review, physical examination, and ECG. All pertinent past medical records were obtained. The patient was 175.2 cm in height, with a mass of 63.5 kg. The patient did not use tobacco products, dietary supplements, or recreational drugs and drank alcohol only socially. At rest, his heart rate, ranging between 35 and 45 bpm, was bradycardic and irregularly irregular, lacking a consistent rhythm. Sinus rhythm was noted at 40 bpm. His blood pressure was 118/72 mmHg.
Supraventricular tachycardia and atrial flutter was confirmed, and the athlete was given an ambulatory ECG loop-event monitor to record SVT events. This allowed for documentation of SVT in a manner by which the patient could comply, without the presence of a health care professional. He was told to continue daily cardiac medications and to ride his bicycle as tolerated, as the risk for sudden cardiac death was deemed low. It is unknown whether the Bethesda Guidelines2 were used in this decision. The electrophysiologist believed a third ablation presented a 50% probability for success, and the patient chose to proceed.
In September 2008, a transesophogeal echocardiogram and chest magnetic resonance imaging were conducted. Neither imaging technique indicated major structural abnormalities of the heart. An electrophysiologic study was first performed to induce SVT. A single, discernible mechanism involving musculature bridging of the right atrium and coronary sinus was found. It was successfully targeted by radiofrequency ablation, which, via catheter electrode, created lesions to eradicate the SVT source.
The athlete was observed for 1.5 days without incident before discharge to home. Both cardiac medication regimens were discontinued. The patient was not placed on any cardiac precautions or given physical activity restrictions. He returned to riding a bicycle and to his job as a stone mason after 2 weeks. He was unable to be supervised or gradually returned to full participation by a sports medicine clinician because medical coverage by an athletic trainer was not provided at his training facility. The patient never returned for follow up with the electrophysiologist.
Currently, the patient is 30 years old. He is 39 months post the third ablation and has denied any incident of SVT while riding his bicycle or otherwise. He has reported sporadic palpitations that are not always exertion related. In March 2011, a graded treadmill test with an ECG, performed by an exercise physiologist, demonstrated between 15 and 18 premature ventricular contractions per minute. The patient denied experiencing cardiac symptoms. In July 2011, a general physical examination revealed that his resting heart rate was bradycardic and irregularly irregular at 45 to 56 bpm. The cause of the continued abnormal heart rate has not been identified. His blood pressure was 100/74 mmHg. An echocardiogram revealed no significant structural defects. He continues with professional BMX.
The patient’s treating physicians have hypothesized that SVT arose from scar tissue that developed from the VSD repair. Atrial flutter rarely occurs in the absence of structural heart disease.2,15 The patient population with grown-up congenital heart disease has been found to have an increased incidence of arrhythmias.1,17–20 It can result from incision location with subsequent scarring or abnormal cardiac physiology producing a myocardial substrate.16,20 A VSD is not indicated as a “common” congenital heart disease, such as an atrial septal defect, that yields SVT.16,18–20
The population with grown-up congenital heart disease also has demonstrated a reduced tolerance for exercise.18 Li et al19 observed a negative correlation between the complexity of the congenital abnormality and reparative surgery and the extent to which atrial flutter limited exercise. Pelliccia et al21 stated that athletic participation should be restricted only in those individuals for whom exercise causes a deterioration or triggers serious tachyarrhythmias. A repaired VSD alone is not cause for exercise restriction.22
Aside from the initial incident, this patient experienced SVT only when participating in freestyle BMX. Use of an ambulatory ECG loop-event monitor proved beneficial, given that SVT could not be elicited in physicians’ offices, and the inability to access sports medicine clinicians during training sessions prevented assessment and documentation of SVT events. Factors such as autonomic nervous system changes, catecholamine release, and psychological responses to riding may have played large roles in this case,2,11 as no other forms of physical activity or exertion yielded SVT.
The patient regularly stated that he was concerned about the potential for SVT to occur each time he participated in BMX. He also became increasingly insecure of his sport-specific skills and apprehensive about sustaining injury, secondary to frequent interruption of practice time by SVT and medication side effects. On the days that he rode BMX, he strictly avoided ingesting stimulants, as they guaranteed an SVT event. On one occasion, SVT occurred after drinking a small amount of hot chocolate before riding.
An emergency department study of adenosine intervention for paroxysmal SVT found that 73% of patients achieved immediate success with a single, 6-mg dose.23 Including patients who required 1 or 2 additional 12-mg doses, adenosine stopped SVT in 89% of patients.23 Radiofrequency ablation is often the treatment of choice for atrial flutter in athletes,15 given the procedure’s high success rate of approximately 95%24 and low risk rate.11,25,26 Physicians have not discussed hypotheses for this patient’s recalcitrant case.
Although a Valsalva maneuver is commonly used both in prehospitalizations and emergency departments to increase vagal tone,1,27 thus breaking the SVT rhythm, it was not successful with this patient. As a result, the patient attempted to find other means to achieve this goal without medical intervention. In 2008, he continued to ride BMX throughout SVT, purposefully elevating his heart rate even higher. Within several minutes, the rhythm would cease, although attempts to continue to ride resulted in the onset of a subsequent SVT. Although the electrophysiologist advised against using this unconventional method, he stated that it did not place the athlete at an increased risk for a cardiac emergency.26 Such audacious maneuvers may have been discouraged by an on-site sports medicine clinician.
Despite this patient’s 3.5-year struggle with SVT, he was able to continue to ride BMX and compete at an elite level, albeit with the consequence of serious injury. Ideally, the quality of riding, inclusive of factors such as fatigue and injury events, should be directly questioned by treating clinicians. The causative factor(s) of a fall should be considered. A sports medicine clinician may be more astute to these factors than other clinicians, justifying a need for their presence in action sports.
A comprehensive medical history, social history, and physical examination are necessary for the delivery of quality and effective health care. It is paramount that sports medicine clinicians recognize their role as athlete health advocates. This is particularly true in cases, such as that presented in this article, where a specific diagnosis and subsequent pharmacological intervention greatly affect athletic participation and injury risk. The quality of health care provided to action sports athletes can be improved as clinicians become more aware of the sport-specific physiological and psychological demands. A sports medicine clinician can take initiative to educate clinicians who are not familiar with a sport, such as in this case where the patient reported that his sport was often mistaken for BMX racing or distance cycling. For example, a sports medicine clinician can explain the crucial need for the athlete to maintain his balance when performing tricks, which had been hindered by taking atenolol.
A strong understanding of how SVT affects both athletic participation and quality of life3 is necessary, including high-risk sports such as freestyle BMX.2,25 Despite the high success rate of radiofrequency catheter ablation for SVT, athletes who have undergone the procedure should be closely monitored for recurrence and complications, further demonstrating a need for sports medicine clinicians to be present in action sports.28
This case of SVT is not directly related to athletic participation. Despite this, the complexity and risk were augmented by the patient’s occupation as a professional freestyle BMX rider. Sports medicine clinicians must be astute to a specific sport’s demands prior to determining an appropriate participation decision for an action sports athlete with SVT. Also, given the risk association with action sport participation, particularly in the presence of a cardiac diagnosis, the availability of sports medicine clinicians at training sessions and competitions can foster a safer environment.
Future research efforts should seek to examine potential relationships between arrhythmias and sports with an aerial component, including causative factors and injury risk. Athletes with cardiovascular abnormalities who participate in sports such as freestyle motocross, gymnastics, snowboarding, and figure skating may be subject to risk not only from their sports’ physical intensity, but also from difficulty in performing skills safely if they experience cardiac symptoms or medication side effects. Guidelines for athletic participation in aerial sports, including action sports, in the presence of cardiovascular abnormalities would be of benefit to both clinicians and athletes.
Implications for Clinical Practice
In this case, athlete safety became of immense concern. The training facility, an action sports camp, is located 30 miles from the closest community hospital and 90 miles from the closest comprehensive medical center. Emergency medical services’ response time is 25 to 30 minutes. From September through May, health care professionals are not on site, and automated external defibrillators are not available. During the summer months, athletic trainers and nurses are present, although in the capacity to provide care to campers. Before a patient is cleared for activity, a physician should consider the availability of on-site medical care.
Although action sports athletes are notorious for being daredevils and sustaining many injuries, there is still a tremendous need for the presence of sports medicine clinicians at training sessions and competitions. In addition to the serious injuries sustained by freestyle BMX riders, the potential for cardiac emergency with an athlete, such as presented herein, warrants immediate accessibility to automated external defibrillators and sports medicine clinicians. In our case, an athletic trainer may have been able to express safety concerns to the cardiologists and relay a thorough understanding of sport-specific demands related to SVT. A sports medicine clinician may have noted an increase in substantial orthopedic injuries as medication side effects worsened and SVT episodes occurred more frequently.
Instances of SVT and medication side effects decreased the patient’s practice time, negatively affecting the patient’s conditioning, motor learning, and comfort level for performing tricks.2,11,12 His fall risk was increased beyond that which is expected for freestyle BMX. Although falls are inherent to action sports, steps can be taken to prevent injuries. The timing of medication administration relative to the commencement of physical activity, nutrition status, and sports psychology techniques to cope with performance anxiety are examples of factors that can potentially be addressed to decrease symptoms or the likelihood for SVT incidence.
Walfridsson and Walfridsson29 examined the effects of SVT on driving ability in patients who have not yet undergone ablation treatment, and they considered those who must drive as part of their occupations. When asked if they had to stop driving while experiencing tachycardia, 42% of patients responded that they had.29 Their symptoms included dizziness, fatigue, near syncope, and syncope.29 This information may be extrapolated to the patient in this case review. Both driving and BMX have an increased injury risk in the presence of SVT. Due to emergency medical services’ response time and lack of the presence of health care professionals, our patient often drove himself to the hospital, which highlights the need for on-site sports medicine clinicians. Despite the symptom-related injury risk, he felt compelled to continue to ride, as athletic participation served as a source of income. Such factors must be considered when determining an appropriate course of treatment, as the needs of an athlete can greatly differ from those of the general population.
Despite an athlete’s strong will to participate, our case highlights the need for the presence of sports medicine clinicians in action sports, both to provide health care services and to serve as advocates for athletes being treated by other clinicians. In addition, this case demonstrates the importance for physicians to consider the big picture as it pertains to the decisions made and care rendered to this unique and underserved population.
- Delacrétaz E. Supraventricular tachycardia. N Engl J Med. 2006;345(10):1039–1051. doi:10.1056/NEJMcp051145 [CrossRef]
- Zipes DP, Ackerman MJ, Estes NA, Grant AO, Myerburg RJ, Van Hare G. Task force 7: arrhythmias. J Am Coll Cardiol. 2005;45(8):1354–1363. doi:10.1016/j.jacc.2005.02.014 [CrossRef]
- Wellens HJ. 25 years of insights into the mechanisms of supraventricular tachycardia. Pacing Clin Electrophysiol. 2003;26(9):1916–1922. doi:10.1046/j.1460-9592.2003.00295.x [CrossRef]
- Naccarelli GV, Varker H, Lin J, Schulman KL. Increasing prevalence of atrial fibrillation and flutter in the United States. Am J Cardiol. 2009;104(11):1534–1539. doi:10.1016/j.amjcard.2009.07.022 [CrossRef]
- Murman DH, McDonald AJ, Pelletier AJ, Camargo CA. U.S. emergency department visits for supraventricular tachycardia 1993–2003. Acad Emerg Med. 2007;14(6):578–581.
- Mitchell JH, Haskell W, Snell P, Van Camp SP. Task force 8: classification of sports. J Am Coll Cardiol. 2005;45(8):1364–1367. doi:10.1016/j.jacc.2005.02.015 [CrossRef]
- Maron BJ. Sudden death in young athletes: lessons from the Hank Gathers affair. N Engl J Med. 1993;329(1):55–57. doi:10.1056/NEJM199307013290113 [CrossRef]
- Vanhees L, Defoor JG, Schepers D, et al. Effect of bisoprolol and atenolol on endurance exercise capacity in healthy men. J Hypertens. 2000;18(1):35–43. doi:10.1097/00004872-200018010-00006 [CrossRef]
- Moreland CM. The Physiological Profile of Elite BMX Freestyle Riders [dissertation]. Fullerton, CA: California State University; 2009.
- Walker J, Calkins H, Nazarian S. Evaluation of cardiac arrhythmia among athletes. Am J Med. 2010;123(12):1075–1081. doi:10.1016/j.amjmed.2010.05.008 [CrossRef]
- Lampert R. Atrial fibrillation in athletes: toward more effective therapy and better understanding. J Cardiovasc Electrophysiol. 2008;19(5):463–465. doi:10.1111/j.1540-8167.2008.01121.x [CrossRef]
- Abdulla J, Nielsen JR. Is the risk of atrial fibrillation higher in athletes than in the general population? A systematic review and meta-analysis. Europace. 2009;11(9):1156–1159. doi:10.1093/europace/eup197 [CrossRef]
- Heidbüchel H, Anné W, Willems R, Adriaenssens B, Van de Werf F, Ector H. Endurance sports is a risk factor for atrial fibrillation after ablation for atrial flutter. Int J Cardiol. 2006;107(1):67–72. doi:10.1016/j.ijcard.2005.02.043 [CrossRef]
- Mont L, Elosua R, Brugada J. Endurance sport practice as a risk factor for atrial fibrillation and atrial flutter. Europace. 2009;11(1):11–17. doi:10.1093/europace/eun289 [CrossRef]
- Link MS, Estes NA. Athletes and arrhythmias. J Cardiovasc Electrophysiol. 2010;21(10):1184–1189. doi:10.1111/j.1540-8167.2010.01808.x [CrossRef]
- Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al. European Society of Cardiology Committee, NASPE-Heart Rhythm Society. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Supraventricular Arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol. 2003;42(8):1493–1531.
- Kalarus Z, Kowalski O, Lenarczyk R, et al. Radio-frequency ablation of arrhythmias following congenital heart surgery. Kardiol Pol. 2006;64(12):1343–1348.
- Li W, Somerville J. Atrial flutter in grown-up congenital heart (GUCH) patients. Clinical characteristics of affected population. Int J Cardiol. 2000;75(2–3):129–137. doi:10.1016/S0167-5273(00)00308-9 [CrossRef]
- Li W, Somerville J, Gibson DG, Henein MY. Effect of atrial flutter on exercise tolerance in patients with grown-up congenital heart (GUCH). Am Heart J. 2002;144(1):173–179. doi:10.1067/mhj.2002.123315 [CrossRef]
- Szili-Torok T, Kornyei L, Jordaens LJ. Transcatheter ablation of arrhythmias associated with congenital heart disease. J Interv Card Electrophysiol. 2008;22(2):161–166. doi:10.1007/s10840-007-9198-6 [CrossRef]
- Pelliccia A, Fagard R, Bjørnstad HH, et al. Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise PhysiologyWorking Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Recommendations for competitive sports participation in athletes with cardiovascular disease: a consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26(14):1422–1445. doi:10.1093/eurheartj/ehi325 [CrossRef]
- Baumgartner H, Bonhoeffer P, DeGroot NM, et al. Task Force on the Management of Grown-up Congenital Heart Disease of the European Society of Cardiology (ESC)Association for European Paediatric Cardiology (AEPC). ESC guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J. 2010;31(23):2915–2957. doi:10.1093/eurheartj/ehq249 [CrossRef]
- Riccardi A, Arboscello E, Ghinatti M, Minuto P, Lerza R. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002–2006). Am J Emerg Med. 2008;26(8):879–882. doi:10.1016/j.ajem.2007.11.029 [CrossRef]
- Fox DJ, Tischenko A, Krahn AD, et al. Supraventricular tachycardia: diagnosis and management. Mayo Clin Proc. 2008;83(12):1400–1411. doi:10.4065/83.12.1400 [CrossRef]
- Furlanello F, Lupo P, Pittalis M, et al. Radiofrequency catheter ablation of atrial fibrillation in athletes referred for disabling symptoms preventing usual training schedule and sport competition. J Cardiovasc Electrophysiol. 2008;19(5):457–462. doi:10.1111/j.1540-8167.2007.01077.x [CrossRef]
- Shapira AR. Catheter ablation of supraventricular arrhythmias and atrial fibrillation. Am Fam Physician. 2009;80(10):1089–1094.
- Smith G, Morgans A, Boyle M. Use of Valsalva manoeuvre in the prohospital setting: a review of the literature. Emerg Med J. 2009;26(1):8–10. doi:10.1136/emj.2008.061572 [CrossRef]
- Miyamoto KJ, Tsuchihashi K, Uno K, et al. Studies on the prevalence of complicated atrial arrhythmias, flutter, and fibrillation in patients with reciprocating supraventricular tachycardia before and after successful catheter ablation. Pacing Clin Electrophysiol. 2001;24(6):969–978. doi:10.1046/j.1460-9592.2001.00969.x [CrossRef]
- Walfridsson U, Walfridsson H. The impact of supraventricular tachycardia on driving ability in patients referred for radiofrequency catheter ablation. Pacing Clin Electrophysiol. 2005;28(3):191–195. doi:10.1111/j.1540-8159.2005.09753.x [CrossRef]