• Cardiology
• Cardiovascular epidemiology
• Concussion

Panhuyzen-Goedkoop and Smeets1 provide an important primer at the intersection of cardiac disorders, decision-making and legal risk in sports medicine. The authors accurately flag the relevant issues and offer concrete suggestions. The purpose of this reply is to elaborate on one of the authors’ key findings and qualify another point through a more textured discussion.

The twin concern of false positives and false negatives permeates the authors’ article. Such an emphasis is well placed. The concern is particularly vexing in the context of cardiac disorders. It was illustrated in the tragic death and legal aftermath involving National Basketball Association player Reggie Lewis, a widely covered event that was recently marked by its 20th anniversary. The past two decades have left a ‘sports law legacy’2—one that all physicians practising in this area should be aware of.

This legacy is premised on the allocation of legal responsibility.3 Cardiologists who practise in the sports realm are intimately aware of the law's overlap—waivers, warnings, consent forms, medical malpractice claims, targeted clauses in insurance policies, risk management guidelines and the growing presence of on-site personnel trained in the use of automated external defibrillators all come to mind. However, none of these should have dispositive priority over the type of best practices outlined by Panhuyzen-Goedkoop and Smeets.

Panhuyzen-Goedkoop and Smeets set forth four findings. All are well grounded. I offer the fifth finding. Namely, when the athlete opts for follow-up cardiac tests as a second opinion, it is critically important that the test be conducted by an independent third-party provider. The athlete's team or organisation should neither pay for the secondary tests nor choose the physician retained to conduct the examinations. Preserving such a clear line of demarcation benefits the athlete and adds an additional layer of legal insulation for the initial physician and the underlying team or athletic association.

Panhuyzen-Goedkoop and Smeets later posit that ‘[g]enetic testing may be helpful in diagnosis and thus in eligibility decision-making’ (this issue) in their discussion of obtaining second opinions. The spectre of increased genetic testing in the sports cardiology context is an incredibly important issue, but far more nuanced than the brief discussion provided to it by the authors. With widespread coverage following the publication of David Epstein's The Sports Gene in 2013,4 the issue remains controversial from a variety of angles.5 All of the angles are relevant to the decision whether sports teams should use genetic tests as either an initial preparticipation diagnostic tool or postincident test to gauge whether the athlete is healthy enough to return to competition.

The wide-ranging legal and quasilegal issues connected to gene-based cardiac examinations reveal that the tests are far from a panacea. The legal status of genetic testing varies across Europe6 and the USA.7 If sports teams or individual physicians avail themselves of genetic tests for cardiology purposes, a delicate balancing act results. The following considerations come into play: (1) whether the patient has granted fully informed consent; (2) the legality of any non-disclosure and privacy policy attached to the genetic test(s) used; (3) possible workplace discrimination issues and (4) concerns pertaining to the ethical use of such tests to determine whether a prospective athlete can participate. Whether an athlete can, at the outset, waive future legal claims via a signed release is a narrow question that differs across national borders. There is no uniform bright-line rule harmonised internationally. As such, it is imperative that any use of genetic tests in this context be deliberated carefully.

Preparticipation (or return to competition) decisions following the discovery of a cardiac disorder, such as the decisions that must be made after concussions8 or other injuries,9 are difficult even without factoring in the legal considerations. Panhuyzen-Goedkoop and Smeets have provided a legal-leaning resource for physicians to consult when making such determinations. The challenging next step will be for jurisdiction-specific guidelines to be crafted, especially in connection with the use of genetic tests focused on the detection of cardiac disorders.