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Thromb Haemost
DOI: 10.1055/a-2632-3197
Review Article

Management of Anticoagulant Therapy in Athletes and Sportspeople: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper

Elena Campello 
1   Internal Medicine 1, Thrombotic and Hemorrhagic Disease Unit, Department of Medicine, Padova University Hospital, Padova, Italy
,
Chiara Cappugi
2   Medicina Interna, Nuovo Ospedale San Giovanni di Dio, Florence, Italy
,
Filippo Catalani
1   Internal Medicine 1, Thrombotic and Hemorrhagic Disease Unit, Department of Medicine, Padova University Hospital, Padova, Italy
3   Department of Internal Medicine, Regional Hospital of Bellinzona e Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
,
Daniela Poli
4   Thrombosis Center, “Careggi” Hospital, Florence, Italy
,
Paolo Bucciarelli
5   Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Abstract

This position paper offers expert guidance on managing anticoagulant therapy in athletes and sportspeople, addressing the unique challenges posed by the dual need for effective thromboprophylaxis and maintenance of athletic performance. Recognizing that conditions such as atrial fibrillation and venous thromboembolism occur with higher prevalence in athletes due to factors like intense physical training, dehydration, trauma, and long-haul travel, the paper reviews current literature and expert opinions from the Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies. The manuscript highlights that although direct oral anticoagulants (DOACs) are generally preferred for their favorable efficacy and safety profile compared with traditional vitamin K antagonists (VKAs), their use in sports demands careful risk stratification. To balance effective anticoagulation with the risk of bleeding, individualized treatment strategies—including intermittent dosing regimens with DOACs—are suggested. These strategies aim to minimize bleeding risk during periods of high physical demand while preserving therapeutic effectiveness. In athletes requiring VKA therapy, sport participation—especially contact or high-impact activities—should be strongly discouraged due to the inability to manage bleeding and thrombotic risks safely. Moreover, the paper emphasizes the importance of periodic re-assessment of thromboembolic and hemorrhagic risks, multidisciplinary collaboration among cardiologists, hematologists, and sports medicine specialists, and shared decision-making with the athlete. By offering practical suggestions on treatment modifications, return-to-play protocols, and patient education, this position paper serves as a critical resource for clinicians striving to optimize anticoagulant therapy in athletic populations without compromising competitive performance.

Keywords

venous thromboembolism - atrial fibrillation - sport medicine - trauma - bleeding

Supplementary Material



Publication History

Received: 07 April 2025

Accepted: 10 June 2025

Accepted Manuscript online:
11 June 2025

Article published online:
24 June 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Kichloo A, Amir R, Wani F, Randhawa S, Rudd B, Rechlin D. Anticoagulation and antiplatelet therapy in contact sports: is it career limiting?. J Investig Med 2021; 69 (03) 781-784
    PubMedSearch in Google Scholar
  • 2 Furlanello F, Bertoldi A, Dallago M. et al. Atrial fibrillation in elite athletes. J Cardiovasc Electrophysiol 1998; 9 (8, Suppl): S63-S68
    PubMedSearch in Google Scholar
  • 3 Grimsmo J, Grundvold I, Maehlum S, Arnesen H. High prevalence of atrial fibrillation in long-term endurance cross-country skiers: echocardiographic findings and possible predictors—a 28-30 years follow-up study. Eur J Cardiovasc Prev Rehabil 2010; 17 (01) 100-105
    PubMedSearch in Google Scholar
  • 4 Koopman P, Nuyens D, Garweg C. et al. Efficacy of radiofrequency catheter ablation in athletes with atrial fibrillation. Europace 2011; 13 (10) 1386-1393
    CrossrefPubMedSearch in Google Scholar
  • 5 Zipes DP, Link MS, Ackerman MJ, Kovacs RJ, Myerburg RJ, Estes III NAM. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 9: Arrhythmias and conduction defects. J Am Coll Cardiol 2015; 66 (21) 2412-2423
    PubMedSearch in Google Scholar
  • 6 Bishop M, Astolfi M, Padegimas E, DeLuca P, Hammoud S. Venous thromboembolism within professional American sport leagues. Orthop J Sports Med 2017; 5 (12) 2325967117745530
    CrossrefPubMedSearch in Google Scholar
  • 7 Eichner ER. Blood clots and plane flights. Curr Sports Med Rep 2009; 8 (03) 106-107
    PubMedSearch in Google Scholar
  • 8 Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease: a case-control study. Chest 1999; 115 (02) 440-444
    PubMedSearch in Google Scholar
  • 9 Parker B, Augeri A, Capizzi J. et al. Effect of air travel on exercise-induced coagulatory and fibrinolytic activation in marathon runners. Clin J Sport Med 2011; 21 (02) 126-130
    PubMedSearch in Google Scholar
  • 10 Hull CM, Harris JA. Venous thromboembolism in physically active people: considerations for risk assessment, mainstream awareness and future research. Sports Med 2015; 45 (10) 1365-1372
    PubMedSearch in Google Scholar
  • 11 Rice SG. American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics 2008; 121 (04) 841-848
    PubMedSearch in Google Scholar
  • 12 Montalvo AM, Schneider DK, Webster KE. et al. Anterior cruciate ligament injury risk in sport: a systematic review and meta-analysis of injury incidence by sex and sport classification. J Athl Train 2019; 54 (05) 472-482
    CrossrefPubMedSearch in Google Scholar
  • 13 Araújo CG, Scharhag J. Athlete: a working definition for medical and health sciences research. Scand J Med Sci Sports 2016; 26 (01) 4-7
    CrossrefPubMedSearch in Google Scholar
  • 14 Van Gelder IC, Rienstra M, Bunting KV. et al; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024; 45 (36) 3314-3414
    CrossrefPubMedSearch in Google Scholar
  • 15 Go AS, Hylek EM, Phillips KA. et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285 (18) 2370-2375
    PubMedSearch in Google Scholar
  • 16 Pelliccia A, Maron BJ, Di Paolo FM. et al. Prevalence and clinical significance of left atrial remodeling in competitive athletes. J Am Coll Cardiol 2005; 46 (04) 690-696
    CrossrefPubMedSearch in Google Scholar
  • 17 Wernhart S, Halle M. Atrial fibrillation and long-term sports practice: epidemiology and mechanisms. Clin Res Cardiol 2015; 104 (05) 369-379
    CrossrefPubMedSearch in Google Scholar
  • 18 Calvo N, Ramos P, Montserrat S. et al. Emerging risk factors and the dose-response relationship between physical activity and lone atrial fibrillation: a prospective case-control study. Europace 2016; 18 (01) 57-63
    CrossrefPubMedSearch in Google Scholar
  • 19 Sanchis-Gomar F, Perez-Quilis C, Lippi G. et al. Atrial fibrillation in highly trained endurance athletes—description of a syndrome. Int J Cardiol 2017; 226: 11-20
    PubMedSearch in Google Scholar
  • 20 Sharma S. Reloaded: Searching for the perfect dose of exercise? In: Proceedings of the Davos Congress. Davos, Switzerland, January 23–26, 2018
    PubMed
  • 21 Newman W, Parry-Williams G, Wiles J. et al. Risk of atrial fibrillation in athletes: a systematic review and meta-analysis. Br J Sports Med 2021; 55 (21) 1233-1238
    CrossrefPubMedSearch in Google Scholar
  • 22 Aizer A, Gaziano JM, Cook NR, Manson JE, Buring JE, Albert CM. Relation of vigorous exercise to risk of atrial fibrillation. Am J Cardiol 2009; 103 (11) 1572-1577
    PubMedSearch in Google Scholar
  • 23 Andersen K, Farahmand B, Ahlbom A. et al. Risk of arrhythmias in 52 755 long-distance cross-country skiers: a cohort study. Eur Heart J 2013; 34 (47) 3624-3631
    CrossrefPubMedSearch in Google Scholar
  • 24 La Gerche A, Schmied CM. Atrial fibrillation in athletes and the interplay between exercise and health. Eur Heart J 2013; 34 (47) 3599-3602
    CrossrefPubMedSearch in Google Scholar
  • 25 Morseth B, Graff-Iversen S, Jacobsen BK. et al. Physical activity, resting heart rate, and atrial fibrillation: the Tromsø Study. Eur Heart J 2016; 37 (29) 2307-2313
    PubMedSearch in Google Scholar
  • 26 Sciarra L, Cavarretta E, Siciliani S. et al. Managing athletes with palpitations of unknown origin with an external loop recorder: a cohort study. J Sports Med Phys Fitness 2022; 62 (04) 554-559
    PubMedSearch in Google Scholar
  • 27 Petrungaro M, Fusco L, Cavarretta E. et al. Long-term sports practice and atrial fibrillation: an updated review of a complex relationship. J Cardiovasc Dev Dis 2023; 10 (05) 218
    PubMedSearch in Google Scholar
  • 28 Minardi S, Sciarra L, Robles AG. et al. Thromboembolic prevention in athletes: management of anticoagulation in sports players affected by atrial fibrillation. Front Pharmacol 2024; 15: 1384213
    PubMedSearch in Google Scholar
  • 29 Sanna GD, Gabrielli E, De Vito E, Nusdeo G, Prisco D, Parodi G. Atrial fibrillation in athletes: from epidemiology to treatment in the novel oral anticoagulants era. J Cardiol 2018; 72 (04) 269-276
    PubMedSearch in Google Scholar
  • 30 Kunutsor SK, Mäkikallio TH, Seidu S. et al. Physical activity and risk of venous thromboembolism: systematic review and meta-analysis of prospective cohort studies. Eur J Epidemiol 2020; 35 (05) 431-442
    PubMedSearch in Google Scholar
  • 31 Evensen LH, Brækkan SK, Hansen JB. Regular physical activity and risk of venous thromboembolism. Semin Thromb Hemost 2018; 44 (08) 765-779
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Swan D, Carter-Brzezinski L, Thachil J. Management of venous thromboembolism in athletes. Blood Rev 2021; 47: 100780
    PubMedSearch in Google Scholar
  • 33 Posthuma JJ, van der Meijden PEJ, Ten Cate H, Spronk HMH. Short- and long-term exercise induced alterations in haemostasis: a review of the literature. Blood Rev 2015; 29 (03) 171-178
    PubMedSearch in Google Scholar
  • 34 El-Sayed MS, El-Sayed Ali Z, Ahmadizad S. Exercise and training effects on blood haemostasis in health and disease: an update. Sports Med 2004; 34 (03) 181-200
    PubMedSearch in Google Scholar
  • 35 Kicken CH, Miszta A, Kelchtermans H, De Laat B. Hemostasis during extreme exertion. Semin Thromb Hemost 2018; 44 (07) 640-650
    PubMedSearch in Google Scholar
  • 36 Zadow EK, Adams MJ, Kitic CM, Wu SSX, Fell JW. Acquired and genetic thrombotic risk factors in the athlete. Semin Thromb Hemost 2018; 44 (08) 723-733
    PubMedSearch in Google Scholar
  • 37 Hirokawa M, Iwai T, Inoue Y, Sato S. Surgical treatment of popliteal vein entrapment causing symptoms. Phlebology 2002; 17 (3-4) 103-107
    PubMedSearch in Google Scholar
  • 38 Leon M, Volteas N, Labropoulos N. et al. Popliteal vein entrapment in the normal population. Eur J Vasc Surg 1992; 6 (06) 623-627
    PubMedSearch in Google Scholar
  • 39 Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost 2005; 3 (11) 2471-2478
    CrossrefPubMedSearch in Google Scholar
  • 40 Shebel ND, Marin A. Effort thrombosis (Paget-Schroetter syndrome) in active young adults: current concepts in diagnosis and treatment. J Vasc Nurs 2006; 24 (04) 116-126
    PubMedSearch in Google Scholar
  • 41 May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8 (05) 419-427
    CrossrefPubMedSearch in Google Scholar
  • 42 Perry M, Kemmis Betty S, Downes N, Andrews N, Mackenzie S. Atrial fibrillation: diagnosis and management—summary of NICE guidance. BMJ 2021 373:n1150
    PubMedSearch in Google Scholar
  • 43 Andrade JG, Aguilar M, Atzema C. et al; Members of the Secondary Panel. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the management of atrial fibrillation. Can J Cardiol 2020; 36 (12) 1847-1948
    CrossrefPubMedSearch in Google Scholar
  • 44 Buka RJ. Andexanet alfa: trials just leave us with more questions. Res Pract Thromb Haemost 2024; 9 (01) 102628
    PubMedSearch in Google Scholar
  • 45 Simioni P, Cipriano A, D'Angelo A. et al. The efficacy and safety of andexanet alfa in the treatment of anticoagulation-related major bleedings: an Italian perspective. Thromb Res 2025; 245: 109241
    PubMedSearch in Google Scholar
  • 46 Lampert R, Chung EH, Ackerman MJ. et al. 2024 HRS expert consensus statement on arrhythmias in the athlete: evaluation, treatment, and return to play. Heart Rhythm 2024; 21 (10) e151-e252
    PubMedSearch in Google Scholar
  • 47 Heidbüchel H, Panhuyzen-Goedkoop N, Corrado D. et al; Study Group on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions Part I: Supraventricular arrhythmias and pacemakers. Eur J Cardiovasc Prev Rehabil 2006; 13 (04) 475-484
    PubMedSearch in Google Scholar
  • 48 Sharma S, Pelliccia A, Gati S. The “Ten Commandments” for the 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42 (01) 6-7
    PubMedSearch in Google Scholar
  • 49 Maron BJ, Zipes DP, Kovacs RJ. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: preamble, principles, and general considerations. J Am Coll Cardiol 2015; 66 (21) 2343-2349
    PubMedSearch in Google Scholar
  • 50 Zeppilli P, Biffi A, Cammarano M. et al. Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2024. Minerva Med 2024; 115 (05) 533-564
    PubMedSearch in Google Scholar
  • 51 Thelle DS, Selmer R, Gjesdal K. et al. Resting heart rate and physical activity as risk factors for lone atrial fibrillation: a prospective study of 309,540 men and women. Heart 2013; 99 (23) 1755-1760
    PubMedSearch in Google Scholar
  • 52 Nazha B, Pandya B, Spyropoulos AC, Kessler CM. Treatment of venous thromboembolism in elite athletes: a suggested approach to individualized anticoagulation. Semin Thromb Hemost 2018; 44 (08) 813-822
    PubMedSearch in Google Scholar
  • 53 Palareti G, Legnani C, Cosmi B, Guazzaloca G, Cini M, Mattarozzi S. Poor anticoagulation quality in the first 3 months after unprovoked venous thromboembolism is a risk factor for long-term recurrence. J Thromb Haemost 2005; 3 (05) 955-961
    PubMedSearch in Google Scholar
  • 54 Kearon C, Akl EA, Ornelas J. et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016; 149 (02) 315-352
    Search in Google Scholar
  • 55 Ortel TL, Neumann I, Ageno W. et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4 (19) 4693-4738
    CrossrefPubMedSearch in Google Scholar
  • 56 Middeldorp S, Nieuwlaat R, Baumann Kreuziger L. et al. American Society of Hematology 2023 guidelines for management of venous thromboembolism: thrombophilia testing. Blood Adv 2023; 7 (22) 7101-7138
    CrossrefPubMedSearch in Google Scholar
  • 57 Weitz JI, Lensing AWA, Prins MH. et al; EINSTEIN CHOICE Investigators. Rivaroxaban or aspirin for extended treatment of venous thromboembolism. N Engl J Med 2017; 376 (13) 1211-1222
    CrossrefPubMedSearch in Google Scholar
  • 58 Agnelli G, Buller HR, Cohen A. et al; AMPLIFY Investigators. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med 2013; 369 (09) 799-808
    CrossrefPubMedSearch in Google Scholar
  • 59 Moll S, Berkowitz JN, Miars CW. Elite athletes and anticoagulant therapy: an intermittent dosing strategy. Hematology Am Soc Hematol Educ Program 2018; 2018 (01) 412-417
    PubMedSearch in Google Scholar
  • 60 Douketis JD, Spyropoulos AC, Duncan J. et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med 2019; 179 (11) 1469-1478
    CrossrefPubMedSearch in Google Scholar
  • 61 Prandoni P, Noventa F, Ghirarduzzi A. et al. The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients. Haematologica 2007; 92 (02) 199-205
    CrossrefPubMedSearch in Google Scholar
  • 62 Carrier M, Le Gal G, Wells PS, Rodger MA. Systematic review: case-fatality rates of recurrent venous thromboembolism and major bleeding events among patients treated for venous thromboembolism. Ann Intern Med 2010; 152 (09) 578-589
    CrossrefPubMedSearch in Google Scholar
  • 63 Testa S, Tripodi A, Legnani C. et al; START-Laboratory Register. Plasma levels of direct oral anticoagulants in real life patients with atrial fibrillation: results observed in four anticoagulation clinics. Thromb Res 2016; 137: 178-183
    PubMedSearch in Google Scholar
  • 64 Testa S, Paoletti O, Legnani C. et al. Low drug levels and thrombotic complications in high-risk atrial fibrillation patients treated with direct oral anticoagulants. J Thromb Haemost 2018; 16 (05) 842-848
    CrossrefPubMedSearch in Google Scholar
  • 65 Squizzato A, Poli D, Barcellona D. et al; Scientific Reviewer Committee. Management of DOAC in patients undergoing planned surgery or invasive procedure: Italian Federation of Centers for the Diagnosis of Thrombotic Disorders and the Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2022; 122 (03) 329-335
    PubMedSearch in Google Scholar
  • 66 Brennan Jr FH. Diagnosis, management of, and return to play guidance for venous thromboembolism in athletes. Curr Sports Med Rep 2022; 21 (04) 129-136
    PubMedSearch in Google Scholar
  • 67 Depenbrock PJ. Thromboembolic disorders: guidance for return-to-play. Curr Sports Med Rep 2011; 10 (02) 78-83
    PubMedSearch in Google Scholar
  • 68 Roberts WO, Christie Jr DM. Return to training and competition after deep venous calf thrombosis. Med Sci Sports Exerc 1992; 24 (01) 2-5
    PubMedSearch in Google Scholar
  • 69 Grabowski G, Whiteside WK, Kanwisher M. Venous thrombosis in athletes. J Am Acad Orthop Surg 2013; 21 (02) 108-117
    CrossrefPubMedSearch in Google Scholar
  • 70 Campello E, Bucciarelli P, Catalani F, Erba N, Squizzato A, Poli D. Scientific Reviewer Committee. Anticoagulant therapy in pregnant women with mechanical heart valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2024; 124 (08) 695-708
    Thieme ConnectPubMedSearch in Google Scholar
  • 71 Monagle P, Cuello CA, Augustine C. et al. American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism. Blood Adv 2018; 2 (22) 3292-3316
    CrossrefPubMedSearch in Google Scholar
  • 72 Witmer C, Raffini L. Treatment of venous thromboembolism in pediatric patients. Blood 2020; 135 (05) 335-343
    CrossrefPubMedSearch in Google Scholar
  • 73 Bastas D, Brandão LR, Vincelli J, Schneiderman JE, Cunningham J, Avila ML. Physical activity for children with deep vein thrombosis and pulmonary embolism on anticoagulation: a scoping review. Res Pract Thromb Haemost 2023; 7 (02) 100094
    PubMedSearch in Google Scholar
  • 74 Bosch A, Olivieri M, Holzhauer S. The use of DOACs in pediatrics: current therapeutic and prophylactic indications, cardiac indications, and real-world evidence—a review. Hamostaseologie 2025; 45 (01) 89-101
    Thieme ConnectPubMedSearch in Google Scholar
  • 75 Male C, Lensing AWA, Palumbo JS. et al; EINSTEIN-Jr Phase 3 Investigators. Rivaroxaban compared with standard anticoagulants for the treatment of acute venous thromboembolism in children: a randomised, controlled, phase 3 trial. Lancet Haematol 2020; 7 (01) e18-e27
    CrossrefPubMedSearch in Google Scholar
  • 76 Young G, Lensing AWA, Monagle P. et al; EINSTEIN-Jr. Phase 3 Investigators. Rivaroxaban for treatment of pediatric venous thromboembolism. An Einstein-Jr phase 3 dose-exposure-response evaluation. J Thromb Haemost 2020; 18 (07) 1672-1685
    CrossrefPubMedSearch in Google Scholar
  • 77 Chao TF, Liu CJ, Wang KL. et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation?. J Am Coll Cardiol 2015; 65 (07) 635-642
    CrossrefPubMedSearch in Google Scholar