Guidance for the Cardiovascular Care of Tactical Athletes

Many articles and guidelines have reviewed the clinical care of recreational and professional athletes, from the preparticipation physical evaluation to the appropriate use of electrocardiography (ECG)  to identify athletes at increased risk of sudden cardiac death. Less attention has been paid to tactical athletes​, who encompass a variety of physically demanding professions such as firefighting, law enforcement, military operations, and space exploration. Since the careers of many of these professionals often extend well beyond the retirement ages of elite competitive athletes, cardiovascular disease exacts an increasing toll. Earlier this month, the American College of Cardiology (ACC) and the American Heart Association (AHA) published a joint scientific statement​ on clinical considerations for the care of the tactical athlete with or at risk for cardiovascular abnormalities.

Although tactical athletes are at increased risk for cardiac events and death while on duty, uniform guidance for this population is lacking. The day-to-day duties of tactical athletes resemble those of many sedentary professions—meetings, administrative work, training—but unlike others, they may be called to respond to a high-risk, high-performance emergency at a moment’s notice. For example, firefighters spend 95% to 99% of their work hours performing other tasks, but actively fighting fires is associated with a 10 to 100 times increased risk of cardiac death​.

Based on expert opinion, the ACC/AHA statement recommends that the preparticipation examination include a screening ECG in all tactical athletes younger than age 40 “who could be exposed to greater than mild cardiovascular strain amplifiers or where the incapacitation of the tactical athlete results in substantial risk to team members, civilians, or mission completion.” Examples include members of search-and-rescue teams or Special Forces soldiers “breaching [a] door with manual techniques” and engaging in combat. The ACC/AHA statement also suggests considering screening for sickle cell trait in tactical athletes “expected to experience … high environmental temperatures, high altitude, and extreme exertion.”

Since older tactical athletes experience atherosclerotic cardiovascular disease events at similar or higher rates than the general population, risk stratification using the PREVENT calculator is appropriate. Common conditions such as hypertension, orthostatic hypotension, and venous thromboembolism may require tailored management to reduce the risk of adverse effects in athletes working in austere environments. Other sections of the ACC/AHA statement address clinical considerations for specific problems in tactical athletes, including genetic cardiomyopathies, myocarditis, congenital heart disease, thoracic aortic disease, syncope and arrhythmias, and cardiac channelopathies.