title: Cardiac pauses in competitive athletes: a systematic review examining the basis of current practice recommendations.
abstract: OBJECTIVE
  It is generally recommended that individuals aspiring to competitive sports should undergo pre-participation cardiovascular assessment, particularly including arrhythmia risk evaluation. In regard to bradyarrhythmias, the 36th Bethesda Conference suggested that asymptomatic cardiac pauses ≤3 s are 'probably of no significance', whereas longer 'symptomatic' pauses may be abnormal. This study focused on assessing the evidence for the '3 s' threshold.
  
  
  METHODS
  A systematic literature search was undertaken including Embase (1980-) and Ovid Medline (1950-). The following MeSH terms were used in the database searches: Cardiac.mp & pause.mp. Additionally, pertinent publications found by review of citation lists of identified publications were examined. Individuals with reversible causes of bradyarrhythmia (e.g. drugs) were excluded.
  
  
  RESULTS
  The study population comprised 194 individuals with cardiac pauses of 1.35-30 s. In 120 athletes, specific records for pause durations were provided, but it was not always clear whether pauses occurred at rest. Among these 120 athletes, 106 had pauses ≤3 s, of whom 92 were asymptomatic and 14 were symptomatic. Fourteen athletes had pauses >3 s, of whom nine were asymptomatic and five were symptomatic. There were no deaths during follow-up (7.46 ± 5.1 years). With respect to symptoms, the ≤3 s threshold had a low-positive predictive value (35.7%) and low sensitivity (26.3%), but good negative predictive value (86.7%) and specificity (91%).
  
  
  CONCLUSIONS
  While the evidence is not incontrovertible, the 3 s pause threshold does not adequately discriminate between potentially asymptomatic and symptomatic competitive athletes, and alone should not be used to exclude potential competitors.
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.|The Department of Cardiology, University of Uludag Medical School, Bursa, Turkey.
authors.forename: Tunay
authors.initials: T
authors.lastname: Senturk
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Hai
authors.initials: H
authors.lastname: Xu
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Krishna
authors.initials: K
authors.lastname: Puppala
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Balaji
authors.initials: B
authors.lastname: Krishnan
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Sakaguchi
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Lin Y
authors.initials: LY
authors.lastname: Chen
authors.affiliation: Division of Cardiology, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
authors.forename: Rehan
authors.initials: R
authors.lastname: Karim
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA.
authors.forename: Oana
authors.initials: O
authors.lastname: Dickinson
authors.affiliation: Cardiac Arrhythmia and Syncope Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Mail Code 508, 420 Delaware Street SE, Minneapolis, MN, USA bendi001@umn.edu.
authors.forename: David G
authors.initials: DG
authors.lastname: Benditt
mesh_terms: D056352:Athletes; D001919:Bradycardia / Q000150:complications*; D016757:Death, Sudden, Cardiac / Q000209:etiology / Q000517:prevention & control*; D006321:Heart / Q000503:physiopathology*; D006801:Humans; D018570:Risk Assessment; D013177:Sports
keywords: Athletes; Bradycardia; Cardiac; Pause; Sports; Symptoms