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

Thromboembolic prevention in athletes: management of anticoagulation in sports players affected by atrial fibrillation

Atrial fibrillation (AF) is a common cardiac arrhythmia that poses a significant risk of stroke and thromboembolic events. Anticoagulation therapy is essential for preventing stroke in patients with AF. An increasing number of people of all ages, including cardiac patients, approach physical activity as both a leisure-time exercise and a competitive sport. Therefore, patients at risk of AF are increasingly allowed to practice sports activities. Management of oral anticoagulant therapy (OAT) in these patients is extremely challenging because of the need to balance the risks and benefits of medications, considering both hemorrhagic (in case of trauma) and ischemic complications when the drugs are avoided. Official recommendations are limited for these patients and forbid sports that increase the risk of trauma and consequent bleeding in most cases. These recommendations are strongly influenced by the "traditional" management of OAT, which mainly involves coumarin derivatives. Non-vitamin K antagonist direct oral anticoagulants (DOACs), with their more favorable pharmacokinetic-pharmacodynamic profile than that of coumarin derivatives, may represent an opportunity to modify the approach to sports activity in patients with AF and indications for OAT. This study aimed to review the use of anticoagulants in athletes with AF, highlight their efficacy and safety, and provide practical considerations regarding their management.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Development of an interpretable machine learning-based intelligent system of exercise prescription for cardio-oncology preventive care: A study protocol

Background

Cardiovascular disease (CVD) and cancer are the first and second causes of death in over 130 countries across the world. They are also among the top three causes in almost 180 countries worldwide. Cardiovascular complications are often noticed in cancer patients, with nearly 20% exhibiting cardiovascular comorbidities. Physical exercise may be helpful for cancer survivors and people living with cancer (PLWC), as it prevents relapses, CVD, and cardiotoxicity. Therefore, it is beneficial to recommend exercise as part of cardio-oncology preventive care.

Objective

With the progress of deep learning algorithms and the improvement of big data processing techniques, artificial intelligence (AI) has gradually become popular in the fields of medicine and healthcare. In the context of the shortage of medical resources in China, it is of great significance to adopt AI and machine learning methods for prescription recommendations. This study aims to develop an interpretable machine learning-based intelligent system of exercise prescription for cardio-oncology preventive care, and this paper presents the study protocol.

Methods

This will be a retrospective machine learning modeling cohort study with interventional methods (i.e., exercise prescription). We will recruit PLWC participants at baseline (from 1 January 2025 to 31 December 2026) and follow up over several years (from 1 January 2027 to 31 December 2028). Specifically, participants will be eligible if they are (1) PLWC in Stage I or cancer survivors from Stage I; (2) aged between 18 and 55 years; (3) interested in physical exercise for rehabilitation; (4) willing to wear smart sensors/watches; (5) assessed by doctors as suitable for exercise interventions. At baseline, clinical exercise physiologist certificated by the joint training program (from 1 January 2023 to 31 December 2024) of American College of Sports Medicine and Chinese Association of Sports Medicine will recommend exercise prescription to each participant. During the follow-up, effective exercise prescription will be determined by assessing the CVD status of the participants.

Expected outcomes

This study aims to develop not only an interpretable machine learning model to recommend exercise prescription but also an intelligent system of exercise prescription for precision cardio-oncology preventive care.

Ethics

This study is approved by Human Experimental Ethics Inspection of Guangzhou Sport University.

Clinical trial registration

http://www.chictr.org.cn, identifier ChiCTR2300077887.

Exercise recommendations for patients with hypertrophic cardiomyopathy

Individuals with hypertrophic cardiomyopathy (HCM) have historically been advised to limit exercise and sports participation to mild-intensity activities due to concerns for sudden cardiac arrest (SCA). However, more contemporary data have shown SCA is rare in patients with HCM and emerging data is shifting towards support for the safety of exercise in this patient population. Recent guidelines endorse exercise in patients with HCM after a comprehensive evaluation and shared-decision making with an expert provider.

Effects of training adaption in endurance athletes with atrial fibrillation: protocol for a multicentre randomised controlled trial

Endurance athletes have a high prevalence of atrial fibrillation (AF), probably caused by exercise-induced cardiac remodelling. Athletes diagnosed with AF are often advised to reduce the intensity and amount of training but the efficacy of this intervention has not been investigated in endurance athletes with AF. Effects of detraining in endurance athletes with atrial fibrillation is a two-arm international multicentre randomised (1:1) controlled trial on the effects of a period of training adaption on AF burden in endurance athletes with paroxysmal AF. One-hundred-and-twenty endurance athletes diagnosed with paroxysmal AF are randomised to a 16-week period of intervention (training adaption) or a control group. We define training adaption as training with a heart rate (HR) not exceeding 75% of the individual maximum HR (HRmax), and total duration of weekly training not exceeding 80% of the self-reported average before the study. The control group is instructed to uphold training intensity including sessions with HR ≥85% of HRmax. AF burden is monitored with insertable cardiac monitors, and training intensity with HR chest-straps and connected sports watches. The primary endpoint, AF burden, will be calculated as the cumulative duration of all AF episodes lasting ≥30sec divided by total duration of monitoring. Secondary endpoints include number of AF episodes, adherence to training adaption, exercise capacity, AF symptoms and health-related quality of life, echocardiographic signs of cardiac remodelling and risk of cardiac arrhythmias related to upholding training intensity.

Trial registration number

NCT04991337.

Study protocol version

4.7 (Date 9 March 2023).

Atrial fibrillation in the athlete: Case report and a contemporary appraisal

INTRODUCTION

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia affecting up to 1% of the world's population. The overwhelming majority of patients with AF have concomitant structural heart disease and comorbidities, including hypertension and diabetes mellitus. One out of ten AF patients has no substantial comorbidities and has been traditionally termed "lone AF". Paradoxically, there exists an association of highintensity endurance exercises and AF.

CASE

43-year-old competitive cyclist and cross-country skier with no known cardiac comorbidities who presented with multiple episodes of dyspnea and palpitations. He was found to have exercise-induced AF without structural heart abnormalities.

DISCUSSION

This case highlights the clinical diversity of AF in athletes. In this review, we delve into the specifics of the pathophysiology and clinical features of AF in athletes. We then review the key points in managing AF in athletes, including medical therapy and catheter ablation.

CONCLUSION

AF in the athletes is incompletely understood due to a lack of prospective study volume. There exist some crucial pathophysiological differences between AF in athletes and AF in older patients with structural heart disease. Treating physicians must be aware of the nuances of management of AF in athletes, including the concepts of detraining, medical therapy options, and ablation.

Exercise and Athletic Activity in Atrial Fibrillation

Moderate-intensity exercise improves cardiovascular outcomes. However, mounting clinical evidence demonstrates that long-term, high-intensity endurance training predisposes male and veteran athletes to an increased risk of atrial fibrillation (AF), a risk that is not observed across both genders. Although increased mortality associated with AF in the general population is not shared by athletes, clinically significant morbidities exist (eg, reduced exercise capacity, athletic performance, and quality of life). Additional research is needed to fill current gaps in knowledge pertaining to the natural history, pathophysiologic mechanisms, and management strategies of AF in the athlete.

Management of Young Athletes with Asymptomatic Preexcitation-A Review of the Literature

INTRODUCTION

The management of young athletes with asymptomatic preexcitation remains a challenge, regardless of the progress we have made in understanding the basis of condition and developing catheter ablation procedures. The risk of sudden death, however small, yet definite, being the first symptom is determining our approach. The aim of the study was to establish the current state of knowledge regarding the management of young athletes diagnosed with asymptomatic preexcitation, by conducting a literature review.

MATERIAL AND METHODS

A comprehensive literature review was completed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was limited to English language publications using the following search terms: "asymptomatic" or "incidental" and "pre-excitation" or "Wolff-Parkinson-White" or "delta wave" and "athlete" or "sport". The search was supplemented by hand review of the bibliographies of previous relevant systematic reviews.

RESULTS

The search resulted in 85 of abstracts, and the manual search of the bibliographies resulted in 24 additional papers. After careful analysis 10 publications were included in the review. In all but one of the presented papers, the authors used non-invasive methods and then either trans-esophageal or invasive EPS as a way to risk stratify asymptomatic patients. Evidence of rapid conduction through the accessory pathway was considered high risk and prompted sport disqualification. In the analysed reports there were combined: 142 episodes of the life-threatening events (LTE)/sudden death (SCD), of which 56 were reported to occur at rest, 61 during activity and no data were available for 25.

CONCLUSIONS

athletic activity may impose an increased risk of life-threatening arrhythmias in patients with asymptomatic preexcitation; hence, a separate approach could be considered, especially in patients willing to engage in high-intensity, endurance and competitive sports.

Abnormal ECG Findings in Athletes: Clinical Evaluation and Considerations

PURPOSE OF REVIEW

Pre-participation cardiovascular evaluation with electrocardiography is normal practice for most sporting bodies. Awareness about sudden cardiac death in athletes and recognizing how screening can help identify vulnerable athletes have empowered different sporting disciplines to invest in the wellbeing of their athletes.

RECENT FINDINGS

Discerning physiological electrical alterations due to athletic training from those representing cardiac pathology may be challenging. The mode of investigation of affected athletes is dependent on the electrical anomaly and the disease(s) in question. This review will highlight specific pathological ECG patterns that warrant assessment and surveillance, together with an in-depth review of the recommended algorithm for evaluation.

The development and codesign of the PATHway intervention: a theory-driven eHealth platform for the self-management of cardiovascular disease

Cardiovascular diseases (CVDs) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of traditional CR remains suboptimal, as attendance at formal hospital-based CR programs is low, with community-based CR rates and individual long-term exercise maintenance even lower. Home-based CR programs have been shown to be equally effective in clinical and health-related quality of life outcomes and yet are not readily available. The aim of the current study was to develop the PATHway intervention (physical activity toward health) for the self-management of CVD. Increasing physical activity in individuals with CVD was the primary behavior. The PATHway intervention was theoretically informed by the behavior change wheel and social cognitive theory. All relevant intervention functions, behavior change techniques, and policy categories were identified and translated into intervention content. Furthermore, a person-centered approach was adopted involving an iterative codesign process and extensive user testing. Education, enablement, modeling, persuasion, training, and social restructuring were selected as appropriate intervention functions. Twenty-two behavior change techniques, linked to the six intervention functions and three policy categories, were identified for inclusion and translated into PATHway intervention content. This paper details the use of the behavior change wheel and social cognitive theory to develop an eHealth intervention for the self-management of CVD. The systematic and transparent development of the PATHway intervention will facilitate the evaluation of intervention effectiveness and future replication.

A randomized controlled trial to evaluate utilization of physical activity recommendations among patients of cardiovascular healthcare centres in Eastern Slovakia: study design and rationale of the AWATAR study

Background

Guidelines on modifiable risk factors regarding cardiological patients are poorly implemented in clinical practice perhaps due to low health literacy. Several digital tools for improving lifestyle and behavioural intervention were developed. Our primary aim is to evaluate the effectiveness of a digital exercise prescription tool on the adherence to physical activity recommendations among patients with cardiovascular diseases.

Methods

A randomized controlled trial will be realized in cooperation with Cardiovascular Health Centres in Eastern Slovakia. Patients recruited through their cardiologists, will be randomised at 1:1 ratio to the three-months’ experimental condition or control condition. The experimental group will receive standard lifestyle consultation leading to individually optimized prescription of physical activity. The control group will receive standard, usual-cardio-care lifestyle counselling, also in the domain of physical activity. The digital system will be used for optimized exercise prescription. The primary outcome is a change in the patient’s adherence to exercise recommendations. Data will be collected in both groups prior to consultation and after 3 months.

Discussion

This study protocol presents background and design of a randomized control trial to investigate the effectiveness of a digital system-provide exercise prescription tool on the adherence to physical activity recommendations. An optimized exercise prescription that better reflects patient’s diagnosis, comorbidities and medication can have a significant impact on secondary prevention of cardiovascular disease. This trial can provide important evidence about the effectiveness of digital exercise guidance in everyday practice of cardiovascular healthcare.

Trial registration

The study was registered on 1st November, 2017 and is available online at ClinicalTrials.gov (ID:NCT03329053).

Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: An Uncontrolled Pilot Study

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Patients often experience a range of symptoms resulting in a markedly reduced quality of life, and commonly show symptom preoccupation in terms of avoidance and control behaviors. Cognitive behavior therapy (CBT) has been shown to improve symptom burden and quality of life in other somatic disorders, but has never been evaluated in patients with AF. The purpose of this study was to evaluate the potential efficacy and feasibility of an AF-specific CBT protocol in an uncontrolled pilot study. The study included 19 patients with symptomatic paroxysmal (intermittent) atrial fibrillation who were assessed pre- and posttreatment and at 6-month follow-up. The CBT lasted 10 weeks and included exposure to physical sensations similar to AF symptoms, exposure to avoided situations or activities, and behavioral activation. We observed large within-group improvements on the primary outcome AF-specific quality of life measurement AFEQT posttreatment (Cohen's d = 1.54; p < . 001) and at 6-month follow-up (d = 1.15; p < . 001). We also observed improvements in self-reported frequency and severity of AF symptoms. All participants completed the treatment and treatment satisfaction was high. This study demonstrates the potential efficacy and feasibility of a novel CBT approach to reduce symptoms and increase quality of life in AF patients.

PATHway I: design and rationale for the investigation of the feasibility, clinical effectiveness and cost-effectiveness of a technology-enabled cardiac rehabilitation platform

INTRODUCTION

Exercise-based cardiac rehabilitation (CR) independently alters the clinical course of cardiovascular diseases resulting in a significant reduction in all-cause and cardiac mortality. However, only 15%-30% of all eligible patients participate in a phase 2 ambulatory programme. The uptake rate of community-based programmes following phase 2 CR and adherence to long-term exercise is extremely poor. Newer care models, involving telerehabilitation programmes that are delivered remotely, show considerable promise for increasing adherence. In this view, the PATHway (Physical Activity Towards Health) platform was developed and now needs to be evaluated in terms of its feasibility and clinical efficacy.

METHODS AND ANALYSIS

In a multicentre randomised controlled pilot trial, 120 participants (m/f, age 40-80 years) completing a phase 2 ambulatory CR programme will be randomised on a 1:1 basis to PATHway or usual care. PATHway involves a comprehensive, internet-enabled, sensor-based home CR platform and provides individualised heart rate monitored exercise programmes (exerclasses and exergames) as the basis on which to provide a personalised lifestyle intervention programme. The control group will receive usual care. Study outcomes will be assessed at baseline, 3 months and 6 months after completion of phase 2 of the CR programme. The primary outcome is the change in active energy expenditure. Secondary outcomes include cardiopulmonary endurance capacity, muscle strength, body composition, cardiovascular risk factors, peripheral endothelial vascular function, patient satisfaction, health-related quality of life (HRQoL), well-being, mediators of behaviour change and safety. HRQoL and healthcare costs will be taken into account in cost-effectiveness evaluation.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the director and clinical director of the PATHway study and by the ethical committee of each participating site. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses and events.

TRIAL REGISTRATION NUMBER

NCT02717806. This trial is currently in the pre-results stage.

Return to play in the athlete with cardiac disease: who decides and what is the protocol?

Improved public awareness and advances in medical diagnostics have resulted in the development of criteria to determine eligibility or disqualification for the athlete with cardiovascular abnormalities. Simultaneously, protocols have been developed for athletes with concussion or orthopaedic injuries to guide team physicians and consultants in return-to-play decisions. However, there are currently inadequate data to allow the development of such protocols for athletes with cardiovascular abnormalities who have undergone treatment. Further complicating the decision process is the designation of the team physician as the ultimate authority in making return-to-play decisions - where the team physician often is an employee of the team and supports the team's goal and players as well as the individual athlete. This review will discuss the ethical dilemma of the team physician and the role of the cardiovascular consultant. Following this, current data and practices regarding return to play will be discussed for the following conditions or diagnoses: following catheter ablation for supraventricular tachycardia; following pacemaker or implantable cardioverter-defibrillator implantation; unexplained syncope; and the athlete with a genetic mutation in the absence of any phenotype of associated disease. These recommendations will undoubtedly continue to evolve and improve and should be considered at this time as a point of departure.

Exercise-Induced Atrial Remodeling: The Forgotten Chamber

Cardiac changes in athletes involve the left ventricle and atrium. Mild left atrial enlargement is common among competitive athletes, possibly a physiologic adaptation to exercise conditioning. The prevalence of this remodeling and the association with supraventricular arrhythmias has not been systematically addressed. Echocardiography screens for patients with disease involving the left atrium. New techniques like speckle tracking can recognize early atrial dysfunction and assess left atrial myocardial function in patients with either physiologic or pathologic left ventricular hypertrophy. This article reviews echocardiographic techniques in delineating the athlete's morphology and functional properties of the left atrium.

Cardiac patients show high interest in technology enabled cardiovascular rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) can slow or reverse the progression of cardiovascular disease (CVD). However, uptake of community-based CR is very low. E-cardiology, e-health and technology solutions for physical activity uptake and monitoring have evolved rapidly and have potential in CVD management. However, it is unclear what the current technology usage is of CVD patients, and their needs and interests for technology enabled CR.

METHODS

A technology usage questionnaire was developed and completed by patients from a supervised ambulatory CR program and an adult congenital heart disease clinic and from two community-based CR programs. Results were described and related with age, gender and educational level by Spearman correlations.

RESULTS

Of 310 patients, 298 patients (77 % male; mean age 61,7 ± 14,5 years) completed at least 25 questions of the survey and were included in the analysis (completion rate 96 %). Most (97 %) patients had a mobile phone and used the internet (91 %). Heart rate monitors were used by 35 % and 68 % reported to find heart rate monitoring important when exercising at home. Physical activity monitoring was reported by 12 % of the respondents. Respondents were interested in CR support through internet (77 %) and mobile phone (68 %). Many patients reported interest in game-based CR (67 %) and virtual rehabilitation (58 %). At least medium interest in technology enabled CR was reported by 75 % of the patients. Interest decreased with increasing age (r = -0.16; p = 0.005).

CONCLUSIONS

CVD patients show interest for technology enabled home-based CR. Our results could guide the design of a technology-based, virtual CR intervention.

Symptoms, diagnoses, and sporting consequences among athletes referred to a Danish sports cardiology clinic

As the number of recreational athletes performing exercise and participating in competitions at a high-level increases, exercise-induced cardiac symptoms may become a more common problem, not least because recreational athletes often continue high-level exercise programs into advanced ages. We investigated the prevalence of cardiac symptoms and diagnoses among 201 athletes referred for cardiac evaluation at a Sports Cardiology Clinic in Denmark. To our knowledge, this is the first systematic study of athletes referred for suspected cardiac disease. The athletes were all well-trained recreational to elite athletes who participated in various sports with different training loads and a wide age span (13-66 years). All patients were referred by physicians, primarily their general practitioner (38%), and palpitations were the most common cardiac symptom (40%). Cardiac symptoms had a sensitivity of 86% in detecting cardiac disease and a specificity of 13%. Cardiac disease was diagnosed in 44% of the patients, and atrial fibrillation was the most prevalent diagnosis (7.5%). Cardiac diseases with therapeutic- or sports-related consequences for the patients were diagnosed in 28% of the population, but only 1% received a recommendation to avoid high-level sports indefinitely.

[Atrial fibrillation and physical activity. An overview]

A training-induced increase in vagal tone, left atrial enlargement and high atrial volume load due to exercise can theoretically favor induction and continuation of atrial fibrillation (AF) in (endurance) athletes. However, there is currently no evidence for a higher occurrence of AF in young endurance athletes in comparison to an age-matched normal population. The correlate of long-term endurance training results in proarrhythmogenic atrial remodeling in a rat model. The results of some studies also suggest that there may be atrial remodeling in humans, which might be an explanation for the comparatively higher incidence of AF in veteran athletes, whereby the relative risk might have been overestimated due to methodological problems, e.g. due to insufficient consideration of "new" AF risk factors. To date, there are no indications for an increased risk of AF due to normal physical activity: on the contrary, moderate physical activity seems to decrease the risk for AF. For an individual evaluation of sports participation of patients with AF, the overall cardiac situation, atrioventricular conduction during exercise, a possible oral anticoagulation as well as the sport and training intensity practiced are important. Well-adapted training for patients with AF has to be considered as safe and effective in terms of the overall positive effects of physical activity in patients with cardiovascular problems, for example due to a positive influence on cardiovascular risk factors.

Nandrolone Plus Moderate Exercise Increases the Susceptibility to Lethal Arrhythmias

Background:

Until now, no experimental study has directly assessed the arrhythmogenesis of chronic consumption of anabolic androgenic steroids along with moderate-intensity endurance exercise.

Objectives:

We evaluated the influence of integration of anabolic androgenic steroids along with moderate-intensity endurance exercise on susceptibility to lethal ventricular arrhythmias in rat.

Materials and Methods:

The animal groups were as follows: control group (CTL); exercise group (EX) which were under 6 weeks of treadmill exercise; nandrolone group (Nan) which received 5 mg/kg of nandrolone decanoate twice a week; vehicle group (Arach) which received Arachis oil (solvent of nandrolone); trained vehicle group (Arach + Ex); and trained nandrolone group (Nan + Ex). One day after ending of the intervention period, arrhythmia was inducted by intravenous infusion of aconitine and ventricular arrhythmias were recorded. Then malondialdehyde (MDA) and glutathione peroxidase (GPX) of heart tissue were measured.

Results:

Nandrolone, exercise, and their combination were associated with heart hypertrophy. Exercise could prevent the incremental effect of nandrolone on MDA/GPX ratio. Chronic administration of nandrolone with moderate-intensity endurance exercise had no significant effect on blood pressure, heart rate, and basal electrocardiographic parameters. Combination of nandrolone and exercise significantly increased the incidence of ventricular fibrillation (VF) and reduced the VF latency (P < 0.05).

Conclusions:

The findings suggest that chronic coadministration of nandrolone with moderate-intensity endurance exercise facilitates the VF occurrence in rat. Complementary studies are needed to elucidate the involved mechanisms of this abnormality.

Endurance Sport Activity and Risk of Atrial Fibrillation - Epidemiology, Proposed Mechanisms and Management

There is evidence for a higher prevalence of atrial fibrillation (AF) in athletes engaged in long-term endurance sports training compared with the general population. Although atrial anatomic adaptations, alterations in autonomic nervous system, chronic systemic inflammation and fibrosis have been proposed as potential mechanisms, they remain speculative. Medical therapy with long-term antiarrhythmic agents or 'pill in the pocket' medications is hampered by limitations, such as sports eligibility and interference with exercise tolerance. AF ablation represents a valid therapeutic option with results similar to these achieved in other patients. Nevertheless, further clinical trials are needed to confirm whether endurance sport practice affects the maintenance of sinus rhythm following catheter ablation of AF.

Exercise and heart disease: from athletes and arrhythmias to hypertrophic cardiomyopathy and congenital heart disease

The beneficial effects of regular physical activity on cardiovascular health are well established, with convincing evidence of improvements in blood pressure, lipid profile and overall mortality. Conversely, individuals with pre-existing congenital, inherited or acquired heart conditions may experience functional cardiac deterioration or sudden death during even moderate exertion. Exclusion from high-level sporting activity may be mandated in some cases, and pre-participation screening of competitive athletes plays an important role in the identification of such individuals. The issue of screening is complicated by the fact that physiological cardiovascular adaptation in healthy athletes, including modest left ventricular hypertrophy and biventricular cavity dilatation, may create a diagnostic overlap with pathological conditions such as hypertrophic cardiomyopathy. Furthermore, much interest has focused recently on the possibility of irreversible cardiac remodeling in a proportion of veteran endurance athletes, with the potential for arrhythmogenesis and adverse cardiac events.

Reduced incidence of cardiac arrhythmias in walkers and runners

Purpose

Walking is purported to reduce the risk of atrial fibrillation by 48%, whereas jogging is purported to increase its risk by 53%, suggesting a strong anti-arrhythmic benefit of walking over running. The purpose of these analyses is to compare incident self-reported physician-diagnosed cardiac arrhythmia to baseline energy expenditure (metabolic equivalent hours per day, METhr/d) from walking, running and other exercise.

Methods

Proportional hazards analysis of 14,734 walkers and 32,073 runners.

Results

There were 1,060 incident cardiac arrhythmias (412 walkers, 648 runners) during 6.2 years of follow-up. The risk for incident cardiac arrhythmias declined 4.4% per baseline METhr/d walked by the walkers, or running in the runners (P = 0.0001). Specifically, the risk declined 14.2% (hazard ratio: 0.858) for 1.8 to 3.6 METhr/d, 26.5% for 3.6 to 5.4 METhr/d, and 31.7% for ≥5.4 METhr/d, relative to <1.8 METhr/d. The risk reduction per METhr/d was significantly greater for walking than running (P<0.01), but only because walkers were at 34% greater risk than runners who fell below contemporary physical activity guideline recommendations; otherwise the walkers and runners had similar risks for cardiac arrhythmias. Cardiac arrhythmias were unrelated to walking and running intensity, and unrelated to marathon participation and performance.

Conclusions

The risk for cardiac arrhythmias was similar in walkers and runners who expended comparable METhr/d during structured exercise. We found no significant risk increase for self-reported cardiac arrhythmias associated with running distance, exercise intensity, or marathon participation. Rhythm abnormalities were based on self-report, precluding definitive categorization of the nature of the rhythm disturbance. However, even if the runners’ arrhythmias include sinus bradycardia due to running itself, there was no increase in arrhythmias with greater running distance.

Atrial fibrillation in endurance athletes

There is a growing population of veteran endurance athletes, regularly participating in training and competition. Although the graded benefit of exercise on cardiovascular health and mortality is well established, recent studies have raised concern that prolonged and strenuous endurance exercise may predispose to atrial and ventricular arrhythmias. Atrial fibrillation (AF) and atrial flutter are facilitated by atrial remodelling, atrial ectopy, and an imbalance of the autonomic nervous system. Endurance sports practice has an impact on all of these factors and may therefore act as a promoter of these arrhythmias. In an animal model, long-term intensive exercise training induced fibrosis in both atria and increased susceptibility to AF. While the prevalence of AF is low in young competitive athletes, it increases substantially in the aging athlete, which is possibly associated with an accumulation of lifetime training hours and participation in competitions. A recent meta-analysis revealed a 5-fold increased risk of AF in middle-aged endurance athletes with a striking male predominance. Beside physical activity, height and absolute left atrial size are independent risk factors for lone AF and the stature of men per se may explain part of their higher risk of AF. Furthermore, for a comparable amount of training volume and performance, male non-elite athletes exhibit a higher blood pressure at rest and peak exercise, a more concentric type of left ventricular remodelling, and an altered diastolic function, possibly contributing to a more pronounced atrial remodelling. The sports cardiologist should be aware of the distinctive features of AF in athletes. Therapeutic recommendations should be given in close cooperation with an electrophysiologist. Reduction of training volume is often not desired and drug therapy not well tolerated. An early ablation strategy may be appropriate for some athletes with an impaired physical performance, especially when continuation of competitive activity is intended. This review focuses on the prevalence, risk factors, and mechanisms of AF in endurance athletes, and possible therapeutic options.

Arrhythmias in the athlete

Regular exercise provides substantial health benefits, mostly by reducing cardiovascular risk factors. However, it may also trigger acute cardiac events and cause sudden cardiac death in individuals with a pre-existing condition. In an otherwise healthy population, intense regular exercise may lead to morphological and electrical cardiac adaptations commonly referred as "athlete's heart." Recent data suggest that this may itself produce structural changes of atrial and ventricular myocardium with enlargement and fibrosis, creating the substrate for development of arrhythmias in apparently healthy athletes. The state of the art in this controversial issue is reviewed.

[Sport for pacemaker patients]

Sport activity is an important issue in many patients with a pacemaker either because they performed sport activities before pacemaker implantation to reduce the cardiovascular risk or to improve the course of an underlying cardiovascular disease (e.g. coronary artery disease, heart failure) by sports. Compared to patients with an implantable cardioverter defibrillator (ICD) the risks from underlying cardiovascular disease (e.g. ischemia, heart failure), arrhythmia, lead dysfunction or inappropriate therapy are less important or absent. Sport is contraindicated in dyspnea at rest, acute heart failure, new complex arrhythmia, acute myocarditis and acute myocardial infarction, valvular disease with indications for intervention and surgery and comorbidities which prevent physical activity. Patients with underlying cardiovascular disease (including hypertension) should preferably perform types and levels of physical activity that are aerobic (with dynamic exercise) such as running, swimming, cycling instead of sport with high anaerobic demands and high muscular workload. In heart failure, studies demonstrated advantages of isometric sport that increases the amount of muscle, thereby preventing cardiac cachexia. Sport with a risk of blows to the chest or physical contact (e.g. boxing, rugby, martial arts) should be avoided. Implantation, programming and follow-up should respect specific precautions to allow optimal physical activity with a pacemaker including implantation of bipolar leads on the side contralateral to the dominant hand, individual programming of the upper sensor and tracking rate and regular exercise testing.

[ECG diagnostics in competitive athletes. Current implications for preparticipation screening]

In young competitive athletes sudden cardiac death frequently occurs as a tragic first manifestation of clinically inapparent underlying structural or electrical cardiac disorders. An increased risk may be reflected by typical electrocardiogram (ECG) alterations preceding symptoms but a correct interpretation is often challenging due to a high prevalence of training-related ECG alterations in competitive athletes mimicking such disorders. Misinterpretation may thus result in either unnecessary disqualification from competitive sports or continuation despite an increased risk or extensive diagnostic work-ups yielding additional equivocal findings. However, as observed in large athlete cohorts in recent years a variety of ECG alterations, such as isolated increased QRS voltage, early repolarization, sinus bradycardia, first degree AV block or incomplete right bundle branch block, represent common variants of ECGs of athletes reflecting physiological and training-related cardiac adaptations. These alterations do not usually require further diagnostic evaluation. In contrast, alterations such as repolarization abnormalities, complete bundle branch block, prolonged QT intervals or pathological Q waves, are strongly suggestive of underlying disorders and require further evaluation even in asymptomatic athletes. Thus, the ECG plays a pivotal role in the prevention of sudden cardiac death in competitive athletes. The present article summarizes current recommendations for the interpretation of athlete ECGs regarding the differentiation between physiological or pathological cardiac adaptation.

Sudden cardiac death in young athletes; a literature review and special considerations in Asia

Sudden cardiac death (SCD) in a young athlete is rare, but catastrophic. Exercise acts as a risk factor for SCD in people with cardiovascular disease. A diversity of cardiovascular disorders including hypertrophic cardiomyopathy, congenital coronary anomalies, arrhythmogenic right ventricular dysplasia, dilated cardiomyopathy, aortic rupture due to Marfan syndrome, myocarditis, valvular disease and electrical disorders (Wolff–Parkinson–White syndrome, long QT syndrome, Brugada syndrome), as well as commotio cordis represent the common causes of SCD in young athletes.

As the outcome of lethal cardiovascular disorders is not reversible except in few cases, effective measures should be addressed to reduce the burden of sudden cardiac death in young athletes. Currently, two types of recommendations are proposed by American and European countries.

It seems that there are some special considerations in Asia, entirely different from North America or Europe, which warrant more comprehensive research on epidemiology and etiology of SCD in young Asian athletes by country and evaluation of current national preventive strategies and their achievements in decreasing the risk. Using these data and considering regional restrictions, an expert group will be able to plan a practical and feasible preventive strategy.

Prevalence and spectrum diseases predisposing to sudden cardiac death: are they the same for both the athlete and the nonathlete?

Sudden cardiac death (SCD) is a rare but devastating event among young people. The precise scale of the event remains undefined. This uncommon but catastrophic event usually is proved to be the consequence of varied unsuspected congenital or acquired cardiovascular diseases. Hypertrophic cardiomyopathy and coronary artery anomalies are the two most frequent causes of SCD. Most commonly, SCD resulting from these diseases occurs during or immediately after exercise. This report highlights the prevalence and spectrum of SCD-predisposing diseases and how they are affected by athletic participation. In addition, disease-specific guidelines for sports participation are addressed.

Cardiac rehabilitation in very old patients: data from the Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008)--official report of the Italian Association for Cardiovascular Prevention, Rehabilitation, and Epidemiology

BACKGROUND

Using data from the Italian SurveY on carDiac rEhabilitation-2008 (ISYDE-2008), this study provides insight into the level of implementation of cardiac rehabilitation (CR) in very old cardiac patients.

METHODS

Data from 165 CR units were collected online from January 28 to February 10, 2008.

RESULTS

The study cohort consisted of 2,281 patients (66.9 ± 11.8 years): 1,714 (62.4 ± 9.6 years, 78% male) aged<75 years and 567 aged ≥ 75 years (80.8 ± 4.5 years, 59% male). Compared with adults, a higher percentage of older patients were referred to CR programs after cardiac surgery or acute heart failure and showed more acute phase complications and comorbidity. Older patients were less likely discharged to home, more likely transferred to nursing homes, or discharged with social networks activation. Older patients had higher death rate during CR programs (odds ratio = 4.6; 95% confidence interval = 1.6-12.9; p = .004).

CONCLUSION

The ISYDE-2008 survey provided a detailed snapshot of CR in very old cardiac patients.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed.