Can Athletes With DVT or PE Return To Play? Fact-Based Rather Than Emotional Reasoning
Stephan Moll, MD1, Joshua Berkowitz, MD2, Philip Blatt, MD, FACP3
Every so often news hit the media that a prominent athlete has had a blood clot: NBA athlete Chris Bosh and NHL’s Steven Stamkos most recently, NBA’s Mirza Teletović and NHL’s Cody McCormick in 2015, tennis player Serena Williams in 2011, just to name a few. For some athletes the occurrence of a blood clot has meant the end of their athletic career.
We believe, however, that with careful medical attention and the proper treatment plan, athletes competing in contact sports can return to full participation in their sport.
Facts and details of the circumstances of any blood clot are needed to understand risks to the patient. You cannot have a meaningful discussion about whether an athlete can safely return to sports without a full understanding of the person’s medical history and current situation. That medical information is rarely made available for public consideration.
This lack of information can breed hyperbole in the media. Words like “life-threatening blood clots” or “playing sports while on blood thinners can be fatal,” are attention-grabbing, but lead to generalizations about risk and treatment that may not apply to a person’s specific circumstances.
Still, blood clots are scary. The common perception is that they can slip into the blood stream and become fatal without warning. In fact, this is unlikely because after a few weeks of treatment they rarely break off and migrate, as they have either dissolved or become scar tissue in the blood vessel.
Blood clots – known as deep vein thrombosis (DVT) when occurring in a leg or arm; or pulmonary embolism (PE) when occurring in the lung – are common in the general population. Typical risk factors are trauma, surgery, immobility, long-distance travel, hormonal birth control and inherited or acquired clotting disorders; but sometimes no obvious risk factor is present.
Historically, it has been taken for granted in the medical community that participation in contact sports during blood thinner therapy is unsafe because any form of trauma will cause minor or major bleeding. However, the availability of a new class of blood thinners may change this paradigm. They quickly reach peak blood thinning activity (within 1.5-3.0 hours) after intake, and are quickly out of the blood stream (within 24-36 hours), making intermittent dosing a feasible management strategy to consider in athletes on blood thinners engaged in contact sports.
Following the initial period of full and uninterrupted blood thinner treatment – often considered to be three months – an athlete can schedule medication dosing with expert medical guidance in a way that only a minimal medication level is present at the time of the contact sport activity. Therapy is then promptly restarted after the activity, once the risk for trauma or bleeding sufficiently normalizes.
The risk of developing a new blood clot with such intermittent dosing is quite low: the chance of an individual dying in a motor vehicle accident this year is 10 times higher than it is for an athlete who interrupts his/her blood thinner therapy for a day.
Everyone has a different perception of risk, and everyone is different in how much risk they are willing to accept. We believe that the core ethical principle of patient autonomy mandates that we as physicians should review reasonable options with an athlete and allow him/her to be a major participant in management decisions factoring in the level of risk he/she is willing to accept.
Other issues also need to be addressed if this proposed strategy is to be implemented. What role do the player’s employer and union have in the decision process? How and by whom is the decision best made when after a game to safely restart the blood thinner? For which practice drills and scrimmages does the athlete need to be off the medication, and which ones prevented from participating in? Can a new therapeutic option be introduced if it appears safe and sensible but scientific data supporting its use is not available and a national “expert consensus agreement” has not yet been established?
Understanding that a number of issues remain unresolved, we nevertheless propose that under appropriate circumstances athletes do not need to be prevented from competing in contact sports because of their history of blood clots or while being treated with blood thinners.
1 Dr. S. Moll – Professor of Medicine, University of North Carolina School of Medicine, Department of Medicine, Division of Hematology-Oncology, Hemophilia and Thrombosis Center, Chapel Hill, NC
2 Dr. J. Berkowitz – Assistant Professor, University of North Carolina School of Medicine, Department of Family Medicine and Sports Medicine, Chapel Hill, NC
3 Dr. P. Blatt – Adjunct Associate Professor of Internal Medicine and Hematology, Duke University Medical Center, Durham, NC
American College of Cardiology Expert Analysis, Oct 19th, 2016. http://www.acc.org/latest-in-cardiology/articles/2016/10/19/15/13/athletes-and-anticoagulation?w_nav=TI
Last updated: Oct 30th, 2016