Pediatric Sports Cardiology Clinic Offers Nuanced Return-to-Play Guidance

A heart murmur, exertional syncope, unexplained chest pain or a concerning family history can raise questions during a routine sports clearance evaluation. For pediatricians, the challenge is not only identifying cardiovascular disease, but also determining whether, when and under what conditions a child can safely return to play.

Cleveland Clinic’s Pediatric Sports Cardiology Clinic was created to help answer that question with timely evaluation and more nuanced guidance than a simple yes-or-no clearance.

For children with possible or known cardiovascular conditions, the clinic offers rapid access — sometimes within 24 hours — to cardiologists with expertise in return-to-play assessment. These specialists provide individualized, sport-specific recommendations that, if feasible, support safe participation.

“Our goal is to get kids back in the game whether or not they have a cardiovascular disease,” says pediatric electrophysiologist Peter Aziz, MD, co-Director of the Pediatric Sports Cardiology Clinic.

“We do not want to restrict patients,” adds clinic co-Director Nicholas Szugye, MD, a pediatric cardiologist who also directs Cleveland Clinic’s Pediatric Cardiopulmonary Exercise Lab. “Physical activity is important for body development and for helping kids live normal lives.”

Why return-to-play decisions have changed

Historically, children with known or suspected cardiovascular disease were often restricted from sports out of caution. While that approach may reduce risk, it also can unnecessarily sideline children from physical activity and its developmental, psychosocial and cardiovascular benefits.

Over time, return-to-play recommendations have evolved due to:

• Better outcomes data for treated patients with inherited arrhythmia syndromes such as long QT syndrome
• Earlier diagnosis and treatment of structural and electrical heart disease
• Improved risk stratification, including exercise-based assessment
• Greater emphasis on shared decision-making among clinicians, families, and schools or athletic programs

“Today, we know that return-to-play decisions are more nuanced,” Dr. Aziz says. “Once a child has proper therapy for a cardiovascular condition, their risk of a cardiac event is much lower — although maybe not zero. They often can return to play, sometimes with modifications or safeguards.”

For example, a teen with treated long QT syndrome may be able to play school soccer if they are adherent to therapy and appropriate safeguards are in place, such as ready access to an AED and personnel trained in CPR.

“Ensuring the child, the parents, and the school or sports organization agree to all of that may be more difficult than simply telling the child they can’t play, but it’s a lot better for the child in the long run,” Dr. Aziz says.

Not just for competitive athletes

The clinic is designed for active children and adolescents, not only competitive athletes.

According to Dr. Szugye, the most common referrals include:

• Athletes flagged during preparticipation screening
• Athletes with exertional chest pain, palpitations, syncope or unexplained exercise intolerance
• Children or adolescents with medical conditions, including heart disease, kidney disease, cancer history or prolonged deconditioning, that may affect cardiovascular performance or exercise tolerance
• Patients with concerning family history, abnormal ECG findings or uncertainty about return-to-play criteria after cardiac surgery or intervention

“Generally, we see kids beginning around ages 9-10, when cardiovascular concerns start to emerge and athletics start to become more competitive,” Dr. Szugye says. “However, we also can see younger patients with symptoms and older kids in high school. Young adults, including college students, transition to our adult sports cardiology group.”

The clinic also sees children recovering from surgery, intervention or prolonged illness who need help returning not only to organized sports, but also to physical education, recess, the playground or other daily activities.

“Let’s say a patient had an anomalous coronary artery that was repaired,” Dr. Aziz says. “They may be following up with their cardiologist, but it can be hard to understand what criteria they need to meet to be cleared to return to the playground. That’s the next layer of expertise that our program provides.”

How the clinic evaluates return-to-play risk

At Cleveland Clinic Children’s, the Pediatric Sports Cardiology Clinic brings together pediatric cardiology, electrophysiology and exercise physiology experts.

The clinical pathway typically includes:

• Review of the referral question, prior records and previous cardiac testing
• A focused visit addressing symptoms, family history, diagnosis, treatment status and sport-specific demands
• Additional testing when indicated
• Individualized return-to-play recommendations, including full clearance, modified participation, safeguards or rehabilitation

For patients with a cardiovascular diagnosis, cardiopulmonary exercise testing can be especially helpful.

“That test can help us determine a patient’s risk — if a patient with an inherited arrhythmia is prone to arrhythmia while they’re running, for example,” Dr. Aziz says. “The test also can help us determine if a patient’s treatment program is effective and sufficient.”

Adds Dr. Szugye, “If the patient is cleared for sports, we’ll send letters to update the referring provider and athletic program. If the patient needs more care, we help them schedule visits with our support network of respiratory, nutrition, sports psychology and other experts.”

Individualized guidance instead of blanket restriction

As awareness grows about the benefits of physical activity for children with cardiovascular conditions, return-to-play decisions increasingly require individualized assessment rather than blanket restriction.

“Our goal is to get kids back to the activities they love as efficiently and safely as possible,” Dr. Aziz says. “We aim to offer easy access to appointments, determine whether there’s an underlying diagnosis and, if there is, develop a plan that helps kids return to play.”

The clinic also emphasizes shared decision-making, recognizing that families need more than a simple clearance recommendation. They need a clear understanding of what a child can do safely and confidently.

“What a physician says and what a family hears can sometimes be two different things,” Dr. Szugye says. “We take the time to evaluate each patient carefully, explain the risks and benefits, and help families feel empowered to make informed decisions.”

While some uncertainty can never be eliminated, Dr. Szugye notes that the risks of lifelong inactivity may, for some patients, outweigh the risks of carefully monitored exercise.

“For many children, the question isn’t whether they should be active, but how we can help them be active safely,” he says. “Instead of automatically saying no, we focus on finding a path forward.”