Italian guidelines for competitive sport eligibility (COCIS): what are the new indications in the updated 2023 version for the evaluation of athletes with arrhythmias?

The COCIS 2023 guidelines represent the latest update on competitive sports eligibility for athletes with heart disease, developed by the Italian Society of Sports Cardiology and associated medical societies. These updated guidelines reflect advancements in cardiology and sports medicine and introduce clear class of recommendations and levels of evidence for assessing athletes with heart disease. This document focuses on the differences between the 2023 and 2017 versions, particularly regarding athletes with arrhythmias. The guidelines integrate new scientific evidence, including modifications to criteria for specific arrhythmic conditions like Wolf-Parkinson-White (WPW) Syndrome, Brugada Syndrome, long QT syndrome (LQTS), and premature ventricular beats (PVBs). Updates on the return-to-play timing after successful catheter ablation are also included. Key updates include the revised arrhythmic risk thresholds for WPW syndrome; these guidelines also expand recommendations for asymptomatic pre-excitation cases. In Brugada Syndrome, eligibility remains dependent on the presence of malignant arrhythmias and genetic risk factors, with scoring systems to aid risk stratification. For LQTS, eligibility is reconsidered for asymptomatic individuals with a negative phenotype and a positive genotype, with beta-blocker use. Additionally, the management of PVBs is refined, with new criteria for further investigation and risk assessment. COCIS 2023 introduces a more nuanced, evidence-based approach to the eligibility of athletes with arrhythmias. The guidelines provide clinicians with detailed recommendations for managing a variety of arrhythmic conditions. As scientific research advances, these guidelines will continue to evolve, ensuring safe athletic participation for individuals with cardiovascular conditions.