Athletes with Implantable Cardioverter-Defibrillators: A Practical Framework for Device Selection, Programming, and Return-to-Sport Risk Mitigation.

Implantable cardioverter-defibrillators (ICDs) were historically viewed as a barrier to vigorous or competitive sport participation, based on theoretical concerns about arrhythmia induction, inappropriate shocks, device damage, and shock-related injury during activity. Contemporary registry data have reframed this paradigm, demonstrating that selected athletes with ICDs can participate in organized sport without the catastrophic outcomes once feared, although these data remain reassuring rather than definitive given selection bias and underrepresentation of high-consequence sports. This review synthesizes contemporary athlete-specific registry data and broader randomized device and programming evidence, alongside current guideline recommendations, to provide a practical framework for the care of athletes with ICDs, addressing indications, which should remain diagnosis-driven rather than sport-driven; device selection, weighing transvenous, subcutaneous, and extravascular platforms against an athlete's pacing needs, anatomy, and sport-specific trauma risk; and exercise-informed device programming. We then present a longitudinal framework integrating clinical readiness, device readiness, sport-specific risk, emergency preparedness, shared decision-making, and reassessment after clinical or sporting changes. Special populations and priorities for future research are also discussed. Rather than a binary clearance decision, modern management of athletes with ICDs requires an individualized, longitudinally reassessed approach to risk.