Cardiovascular Risk Profile in Master Paralympic Athletes, a High-Risk Undertreated Population: A Cross-Sectional Longitudinal Study

INTRODUCTION

Recently, European Society of Cardiology (ESC) validated a prediction model to estimate 10-year fatal and non-fatal cardiovascular disease risk (CVDR) in individuals (aged 40-60 years) without previous cardiovascular disease or diabetes (ESC-SCORE2) and to provide indications for treatment. At present, data describing the CVDR in Paralympic athletes (PAs) are scarce and inconsistent. Therefore, we sought to assess the prevalence of risk factors in PAs to estimate their CVDR through SCORE2.

METHODS

We enrolled 99 PAs aged ≥ 40 y.o., who participated at 2012-2022 Paralympic Games, competing in 22 different sport disciplines classified according to sport type (power, skills, endurance and mixed) and disabilities: spinal cord injuries (SCI) and non-SCI. CVDR factors, anthropometric measurements and blood samples were collected.

RESULTS

Among the 99 PAs (78% males, mean age 45.7 ± 4.7 y.o.), 52.5% had SCI; 54% were dyslipidemic and 23% were smokers. According to ESC-SCORE2, 29% had high and 1% very-high CVDR. Women (compared to men) and endurance (compared to other sport) exhibited better CV profile. SCI showed no differences when compared with non-SCI for CVDR, excepted for a lower HDL and lower exercise performance. None of the dyslipidemic athlete was on pharmacologically treatment, despite the altered lipid profile had already been detected at younger age.

CONCLUSION

PAs are a selected population, presenting a high CV risk profile, with 30% showing either high or very-high CVDR according to ESC-SCORE2. Dyslipidemia was the most common risk factor, underestimated and undertreated, emphasizing the need for specific preventive strategies in this special setting of athletes.

The role of cardiac magnetic resonance in sports cardiology: results from a large cohort of athletes

BACKGROUND

Cardiac magnetic resonance (CMR) provides information on morpho-functional abnormalities and myocardial tissue characterisation. Appropriate indications for CMR in athletes are uncertain.

OBJECTIVE

To analyse the CMR performed at our Institute to evaluate variables associated with pathologic findings in a large cohort of athletes presenting with different clinical conditions.

METHODS

All the CMR performed at our Institute in athletes aged > 14 years were recruited. CMR indications were investigated. CMR was categorised as "positive" or "negative" based on the presence of morphological and/or functional abnormalities and/or the presence of late gadolinium enhancement (excluding the right ventricular insertion point), fat infiltration, or oedema. Variables associated with "positive" CMR were explored.

RESULTS

A total of 503 CMR were included in the analysis. "Negative" and "positive" CMR were 61% and 39%, respectively. Uncommon ventricular arrhythmias (VAs) were the most frequent indications for CMR, but the proportion of positive results was low (37%), and only polymorphic ventricular patterns were associated with positive CMR (p = 0.006). T-wave inversion at 12-lead ECG, particularly on lateral and inferolateral leads, was associated with positive CMR in 34% of athletes (p = 0.05). Echocardiography abnormalities resulted in a large proportion (58%) of positive CMR, mostly cardiomyopathies.

CONCLUSION

CMR is more efficient in identifying a pathologic cardiac substrate in athletes in case of VAs (i.e., polymorphic beats), abnormal ECG repolarisation (negative T-waves in inferolateral leads), and borderline echocardiographic findings (LV hypertrophy, mildly depressed LV function). On the other hand, CMR is associated with a large proportion of negative results. Therefore, a careful clinical selection is needed to indicate CMR in athletes appropriately.

Lack of cardiac remodelling in elite endurance athletes: an unexpected and not so rare finding

PURPOSE

Endurance elite athletes are expected to present a cardiac remodelling, characterized by eccentric hypertrophy (EH), may be associated with higher sportive performances. However, not all can present a cardiac remodelling. The study aimed to identify endurance athletes without cardiac remodelling characterizing their physiologic and clinical features.

METHODS

We studied 309 endurance athletes (cycling, rowing, canoeing, triathlon, athletics, long-distance swimming, cross-country skiing, mid-long distance track, pentathlon, biathlon, long-distance skating and Nordic-combined) examined during period of training, by clinical evaluation, ECG, echocardiogram and exercise-stress test. Sport career achievements (Olympic\World championship medals or national\world records) were recorded.

RESULTS

EH was found in most of athletes, (n = 126, 67% of males; n = 85, 68.5% of females). A significant proportion,, exhibited normal geometry (NG) ( n = 59, 31.3% in males; n = 39, 31.4% in females). At stress test, significant differences between EH and NG athletes were found in peak power (317.1 ± 71.2W in NG vs. 342.2 ± 60.6W in EH, p = 0.014 in males and 225.1 ± 38.7W in NG vs. 247.1 ± 37W in EH, p = 0.003 in females), rest heart rate (66.1 ± 13 in NG vs. 58.6 ± 11.6 in EH, p = 0.001 in males and 68 ± 13.2 in NG vs. 59.2 ± 11.2 in EH, p = 0.001 in females) with similar ventricular extrasystoles (p = 0.363 in males and p = 0.492 in females). However, no significant differences in athletic achievements were registered.

CONCLUSION

Our study demonstrates a relatively high prevalence of NG in endurance athletes, in addition to the expected EH. Athletes with NG perform worse in exercise-stress test and exhibit some less advantageous functional heart characteristics. However, the type of heart geometry is not associated with negative clinical findings.

Electrical and structural remodelling in female athlete's heart: A comparative study in women vs men athletes and controls

BACKGROUND

Athlete's heart is associated with physiological electrical and structural remodelling. Despite the plethora of data published on male athletes, solid data derived from female athletes, compared to male counterparts or sedentary women, are still scarce.

OBJECTIVES

We aimed to analyze the electrical, structural, and functional characteristics of athlete's heart in female and male athletes vs sedentary controls.

METHODS

Olympic athletes and sedentary controls were evaluated by resting ECG and echocardiography. Athletes were divided into 4 different sports groups.

RESULTS

The study population included 1096 individuals (360 female athletes, 410 male athletes, 130 sedentary women and 196 sedentary men). Female athletes had lower resting heart rate, longer PR interval, higher voltage of R, and T waves and more frequently incomplete RBBB, left ventricular (LV) hypertrophy, early repolarization, and anterior T-wave inversion as compared to controls. Biventricular cavity dimensions and LV wall thickness were greater in female athletes than in female controls. However, women showed a lower degree of training-induced structural remodelling than men. In female athletes, both cavity dimensions and LV wall thickness increased from those engaged in skill and power to mixed and endurance disciplines. However, in female athletes, contrary to males, the ECG changes were not significantly different according to the different types of sport discipline.

CONCLUSIONS

Highly-trained women demonstrate relevant training-induced electrical and structural remodelling. However, the type of sport did not influence ECG parameters in women, contrary to men, while it impacted biventricular morphologic remodelling, with endurance athletes showing the greatest degree of adaptation.

Left Ventricular Trabeculation: Arrhythmogenic and Clinical Significance in Elite Athletes

INTRODUCTION

Left ventricular (LV) trabeculations (LVTs) are common findings in athletes. Limited information exists regarding clinical significance, management, and outcome.

OBJECTIVES

The purpose of this study is to examine the prevalence and morphologic characteristics of LVTs in elite athletes, with a focus on clinical correlates and prognostic significance.

METHODS

We enrolled 1,492 Olympic elite athletes of different sports disciplines with electrocardiogram, echocardiogram, and exercise stress test. Individuals with a definite diagnosis of LV noncompaction (LVNC) were excluded; we focused on athletes with LVTs not meeting the criteria for LVNC.

RESULTS

Four hundred thirty-five (29.1%) athletes presented with LVTs, which were more frequent in male athletes (62.1% vs 53.5%, P = .002) and Black athletes compared with Caucasian (7.1% vs 2.4%, P < .0001) and endurance athletes (P = .0005). No differences were found with relation to either the site or extent of trabeculations. Endurance athletes showed a higher proportion of LVTs and larger LV volumes (end-diastolic and end-systolic, respectively, 91.5 ± 19.8 mL vs 79.3 ± 29.9 mL, P = .002; and 33.1 ± 10 mL vs 28.6 ± 11.7 mL, P = .007) and diastolic pattern with higher E wave (P = .01) and e' septal velocities (P = .02). Ventricular arrhythmias were found in 14% of LVTs versus 11.6% of athletes without LVTs (P = .22). Neither the location nor the LVTs' extension were correlated to ventricular arrhythmias. At 52 ± 32 months of follow-up, no differences in arrhythmic burden were observed (11.1% in LVT athletes vs 10.2%, P = .51).

CONCLUSIONS

Left ventricular trabeculations are quite common in athletes, mostly male, Black, and endurance, likely as the expression of adaptive remodeling. In the absence of associated clinical abnormalities, such as LV systolic and diastolic impairment, electrocardiogram repolarization abnormalities, or family evidence of cardiomyopathy, athletes with LVTs have benign clinical significance and should not require further investigation.

Cardiovascular Effects of Chronic Hormone Therapy: Study on Olympic Female Athletes

Female physiology is regulated after puberty by the menstrual cycle, whose hormonal fluctuations create a multitude of effects on several systems, including the cardiovascular one. The use of hormone therapy (HT) is quite common in female athletes, and data on cardiovascular effects in this population are lacking. We sought to investigate the effects of HT in highly trained athletes to assess any difference associated with HT on cardiac remodeling, exercise capacity, and clinical correlates. We studied 380 female elite athletes (mean age 25.5 ± 4.8) competing in endurance and mixed sports; 67 athletes (18%) were in chronic HT therapy. All athletes underwent baseline electrocardiography, exercise electrocardiography stress test, transthoracic echocardiogram, and complete blood tests, including lipid profile and inflammation indexes. The echocardiographic study showed a characteristic left ventricular (LV) remodeling, defined by lower LV mass index (86.2 vs 92.5 g/m2, p <0.006), end-diastolic LV diameter (28.3 vs 29.4 mm/m2, p <0.004), and end-diastolic LV volume (61.82 vs 67.09 ml/m2, p <0.010) compared with controls, without changes in systolic function and diastolic relaxation/filling indexes. A lower burden of ventricular arrhythmias on exercise was observed in HT athletes (1.5% vs 8.6% in those without therapy, p = 0.040). Linear regression analysis showed that HT had an independent effect on LV end-diastolic diameter indexed (p = 0.014), LV end-diastolic volume indexed (p = 0.030), and LV mass indexed (p = 0.020). In conclusion, chronic treatment with HT in female athletes is associated with less cardiac remodeling, including a lower LV cavity, volume, and mass, with preserved systolic and diastolic function, and decreased burden of exercise-induced ventricular arrhythmias. HT, therefore, appears to be responsible for a more economic but equally efficient cardiac adaptation to intensive athletic conditioning.

Prevalence and clinical significance of low QRS voltages in healthy individuals, athletes and patients with cardiomyopathy: implications for sports preparticipation cardiovascular screening

Low QRS voltages (LQRSV), defined as a QRS amplitude from peak to nadir <0.5 mV in all limb leads, are an emerging diagnostic finding on the electrocardiogram (ECG). In healthy individuals and athletes, LQRSV are rare (2.2-4% of elite athletes, 0.5% of recreational athletes and 0.3% of sedentary individuals). LQRSV athletes commonly show ventricular arrhythmias (VAs) on exercise, and up to 40% of those with LQRSV and VAs have late gadolinium (LGE) on cardiac magnetic resonance (CMR). The prevalence of LQRSV in arrhythmogenic cardiomyopathy (ACM) ranges 17-40%, predicts left ventricular (LV) involvement, and is correlated with more extensive LGE replacement on CMR. In hypertrophic cardiomyopathy (HCM), LQRSV ranges 0.7% to 11%. LQRSV-HCM patients have more segments with LGE, despite relatively smaller LV mass, suggesting a more advanced clinical stage and a worse prognosis. In dilated cardiomyopathy (DCM), LQRSV range 6%-7%, but may be higher (36%) in certain genetic forms of DCM. On a follow-up, LQRSV are independently associated with incident cardiac events, such as sudden death, sustained ventricular arrhythmia, or appropriate internal cardioverter defibrillator discharge. In cardiac amyloid (CA), LQRSV range from 34% to 66% and demonstrate a negative prognostic value, with worse clinical outcomes regardless of underlying biologic, genetic, and clinical variables. In conclusion, LQRSV deserve careful consideration for exclusion of arrhythmogenic substrates in healthy individuals, athletes, and patients. While additional research is needed, it is reasonable that LQRSV should trigger clinical investigation to exclude underlying diseases at risk of life-threatening arrhythmias.

Prevalence of Hyperuricemia and Associated Cardiovascular Risk Factors in Elite Athletes Practicing Different Sporting Disciplines: A Cross-Sectional Study

Uricemia has been identified as an independent risk factor for cardiovascular disease. In the general population, hyperuricemia is associated with hypertension, endothelial dysfunction, and other cardiovascular risk (CVR) factors. Our aim was to explore the prevalence of hyperuricemia among Olympic athletes, evaluating the influence of sporting discipline and its correlation with CVR factors. We enrolled 1173 Olympic athletes classified into four disciplines: power, skill, endurance, and mixed. Clinical, anthropometric data, and complete blood test results were collected. Hyperuricemia was present in 4.4% of athletes, 0.3% were hypertensive, 11.7% had high-normal blood pressure values, 0.2% were diabetic, 1.2%. glucose intolerance, 8.2% active smokers, and 3% were obese. Males had a higher prevalence of hyperuricemia (5.3%) than females (3.4%) with no significant differences between different sporting disciplines (male, p = 0.412; female p = 0.561). Males with fat mass >22% presented higher uricemia (5.8 ± 1 vs. 5.3 ± 1 mg/dL, p = 0.010) like hypertensive athletes (6.5 ± 0.3 vs. 5.3 ± 1 mg/dL, p = 0.031), those with high-normal blood pressure (5.13 ± 1 vs. 4.76 ± 1.1 mg/dL, p = 0.0004) and those with glucose intolerance (6 ± 0.8 vs. 5.3 ± 1 mg/dL, p = 0.066). The study provides a comprehensive evaluation of hyperuricemia among Olympic athletes, revealing a modest prevalence, lower than in the general population. However, aggregation of multiple CVR factors could synergistically elevate the risk profile, even in a population assumed to be at low risk. Therefore, uric acid levels should be monitored as part of the CVR assessment in athletes.

Proposed diagnostic criteria for arrhythmogenic cardiomyopathy: European Task Force consensus report

Arrhythmogenic cardiomyopathy (ACM) is a heart muscle disease characterized by prominent "non-ischemic" myocardial scarring predisposing to ventricular electrical instability. Diagnostic criteria for the original phenotype, arrhythmogenic right ventricular cardiomyopathy (ARVC), were first proposed in 1994 and revised in 2010 by an international Task Force (TF). A 2019 International Expert report appraised these previous criteria, finding good accuracy for diagnosis of ARVC but a lack of sensitivity for identification of the expanding phenotypic disease spectrum, which includes left-sided variants, i.e., biventricular (ABVC) and arrhythmogenic left ventricular cardiomyopathy (ALVC). The ARVC phenotype together with these left-sided variants are now more appropriately named ACM. The lack of diagnostic criteria for the left ventricular (LV) phenotype has resulted in clinical under-recognition of ACM patients over the 4 decades since the disease discovery. In 2020, the "Padua criteria" were proposed for both right- and left-sided ACM phenotypes. The presently proposed criteria represent a refinement of the 2020 Padua criteria and have been developed by an expert European TF to improve the diagnosis of ACM with upgraded and internationally recognized criteria. The growing recognition of the diagnostic role of CMR has led to the incorporation of myocardial tissue characterization findings for detection of myocardial scar using the late‑gadolinium enhancement (LGE) technique to more fully characterize right, biventricular and left disease variants, whether genetic or acquired (phenocopies), and to exclude other "non-scarring" myocardial disease. The "ring-like' pattern of myocardial LGE/scar is now a recognized diagnostic hallmark of ALVC. Additional diagnostic criteria regarding LV depolarization and repolarization ECG abnormalities and ventricular arrhythmias of LV origin are also provided. These proposed upgrading of diagnostic criteria represents a working framework to improve management of ACM patients.

Influence of the Type of Disability and Sporting Discipline on Lipid Profile in a Cohort of Italian Paralympic Athletes

Dyslipidemia is the most frequent cardiovascular (CV) risk factor in able-bodied athletes and is frequently undertreated, resulting in an underestimated risk of atherosclerosis-related diseases. Data on lipid profile in Paralympic athletes are lacking. Our study aimed to identify the prevalence of dyslipidemia and the influence of disability type and sporting discipline in Paralympic athletes. We evaluated 289 athletes who participated in the Paralympic Games from London 2012 to Beijing 2022. All athletes underwent clinical/physical evaluation, blood tests, and body composition analysis. They were divided into different groups based on sports disciplines and disability type (spinal cord injuries [SCIs] and non-SCIs [NSCIs]). Among the Paralympic athletes, 34.6% had a low-density lipoprotein (LDL) level ≥115 mg/100 ml. They were older (38.1 ± 9.2 vs 30.6 ± 9.6, p = 0.001) and had a higher CV risk. Athletes with SCI showed similar total cholesterol and triglycerides, higher LDL (110.9 ± 35.2 vs 102.7 ± 30.6 mg/100 ml, p = 0.03) and lower high-density lipoprotein (HDL) (53.6 ± 13.6 vs 60.5 ± 15.4 mg/100 ml, p = 0.001) than those with NSCI. Endurance athletes had lower LDL, the highest HDL, and the lowest triglycerides and LDL/HDL ratio compared with other sports disciplines. A mean follow-up of 61.5 ± 30.5 months was available in 47% athletes, and 72.7% of the athletes with dyslipidemia continued to present altered LDL values at follow-up. In conclusion, dyslipidemia is the most common CV risk factor in the Paralympics, affecting 35% of athletes, with only mild lipid changes over a medium-term time. The type of disability and sporting discipline has an impact on lipids, improving HDL and reducing LDL, with a better profile observed in NSCI and endurance athletes.

Influence of isometric versus isotonic exercise training on right ventricular morpho-functional parameters in Olympic athletes

BACKGROUND

Cardiovascular adaptations in elite athletes involve both ventricular and atrial changes. Nowadays, limited research exists on right ventricular (RV) remodeling, particularly in female athletes and across different types of exercise training.

METHODS

Our study evaluated 370 athletes (61% males) participated at 2020 Tokyo and 2022 Beijing Olympic Games. Athletes were categorized according to main type of exercise into isometric and isotonic. Comprehensive echocardiographic assessments were conducted to analyze RV morpho-functional parameters, comparing genders and different sporting exercise.

RESULTS

Significant differences in RV parameters were observed based on exercise type and gender. Isotonic athletes showed greater RV remodeling with larger RV outflow tract (15.1 ± 2.1 vs. 14.5 ± 1.7 mm, p < .0001) end-diastolic and end-systolic area (respectively, 24.6 ± 5.5 vs. 21.7 ± 5 mm, p < .000 and 11.7 ± 3.2 vs. 10.1 ± 2.8 mm, p < .0001) and right atrium size (11.7 ± 3.2 vs. 10.2 ± 2.3 mm2 , p = .0001). Functional parameters, such as TDI velocities, were similar between groups. Males showed larger RV area and right atrium size (p < .0001) and lower RV TDI velocities with reduced E' (15.4 ± 2.9 vs. 16.1 ± 3.2 m/s in females, p = .031), resulting in lower E'/A' ratio (1.69 ± .6 vs. 1.84 ± .6 m/s, p = .021), while S' was lower females (14.6 ± 2.3 vs. 14.1 ± 2.4 m/s, p = .041). RV TDI velocities were similar in isotonic and isometric both in male and females.

CONCLUSIONS

In elite athletes, RV morphological changes are influenced by exercise modality but do not translate into functional differences. Female athletes present distinct RV functional profiles, with lower S' velocities and a higher E'/A' ratio. Functional RV TDI parameters are not affected by the typology of exercise practiced.

Cardiovascular and metabolic effects of hyperbilirubinemia in a cohort of Italian Olympic athletes

INTRODUCTION

Bilirubin was supposed to have cardio-metabolic protective role by signaling functions. Indeed, mild hyperbilirubinemia has immunosuppressive and endocrine activities and may offer protection against oxidative stress-mediated diseases. Gilbert syndrome (GS) has been hypothesized to provide cardio-metabolic benefits.

OBJECTIVE

To investigate the prevalence of hyperbilirubinemia and its cardio-metabolic effects in a cohort of elite Italian athletes engaged in different sports disciplines.

METHODS

We enrolled 1492 elite athletes (age 25.8 ± 5.1) practising different disciplines (power, skills, endurance, and mixed) underwent blood, echocardiographic, and exercise tests. GS was diagnosed per exclusionem in athletes with isolated asymptomatic unconjugated hyperbilirubinemia.

RESULTS

GS was highlighted in 91 athletes (6%; globally 9% male and 2.4% female); 82% were males (p < 0.0001) showing higher indirect bilirubin (0.53 ± 0.4 vs. 0.36 ± 0.24 mg/dL in females, p < 0.0001). GS athletes had fewer platelets (201 ± 35 vs. 214 ± 41, p = 0.01), higher iron (male: 124 ± 44 vs. 100.9 ± 34 mcg/dL, p < 0.0001; female: 143.3 ± 35 vs. 99.9 ± 42 mcg/dL, p < 0.0001), and lower erythrocyte sedimentation rate, (1.93 ± 0.9 vs. 2.80 ± 2.7 mm/H, p = 0.03). At multivariate analysis, male (OR 3.89, p = 0.001) and iron (OR 3.47, p = 0.001) were independently associated with GS. No significant differences were found in cardiac remodeling, heart rate, blood pressure, arrhythmias, or power capacity at stress test. Endurance athletes (313) presented higher total (p = 0.003) and indirect bilirubin (p = 0.001).

CONCLUSION

Bilirubin has several metabolic effects (including immunosuppressive and endocrine) and plays a role in regulating antioxidant pathways exercise-related with hematological consequences but seems not to affect significantly cardiovascular remodeling. Endurance athletes present higher bilirubin concentrations, likely as an adaptive mechanism to counteract increased oxidative stress.

Periodic health evaluation in athletes competing in Tokyo 2020: from SARS-CoV-2 to Olympic medals

Background

The Tokyo Olympic games were the only games postponed for a year in peacetime, which will be remembered as the COVID-19 Olympics. No data are currently available on the effect on athlete's performance.

Aim

To examine the Italian Olympic athletes who have undergone the return to play (RTP) protocol after COVID-19 and their Olympic results.

Methods

642 Potential Olympics (PO) athletes competing in 19 summer sport disciplines were evaluated through a preparticipation screening protocol and, when necessary, with the RTP protocol. The protocol comprised blood tests, 12-lead resting ECG, transthoracic echocardiogram, cardiopulmonary exercise test, 24-hour Holter-ECG monitoring and cardiovascular MR based on clinical indication.

Results

Of the 642 PO athletes evaluated, 384 participated at the Olympic Games, 254 being excluded for athletic reasons. 120 athletes of the total cohort of 642 PO were affected by COVID-19. They were evaluated with the RTP protocol before resuming physical activity after a mean detraining period of 30±13 days. Of them, 100 were selected for Olympic Games participation, 16 were excluded for athletic reasons and 4 were due to RTP results (2 for COVID-19-related myocarditis, 1 for pericarditis and 1 for complex ventricular arrhythmias). Among athletes with a history of COVID-19 allowed to resume physical activity after the RTP and selected for the Olympic Games, no one had abnormalities in cardiopulmonary exercise test parameters, and 28 became medal winners with 6 gold, 6 silver and 19 bronze medals.

Conclusions

Among athletes with COVID-19, there is a low prevalence of cardiac sequelae. For those athletes allowed to resume physical activity after the RTP evaluation, the infection and the forced period of inactivity didn't have a negative impact on athletic performance.

Interpretation and management of premature ventricular beats in athletes: An expert opinion document of the Italian Society of Sports Cardiology (SICSPORT)

Premature ventricular beats (PVBs) are recorded in a sizeable proportion of athletes during pre-participation screening, especially if the evaluation includes both resting and exercise ECG. While in the majority of cases no underlying heart disease is present, in others PVBs may be the sign of a condition at risk of sudden cardiac death, including cardiomyopathies, congenital, coronary artery, heart valves and ion channels diseases. In this expert opinion document of the Italian Society of Sports Cardiology, we propose a multiparametric interpretation approach to PVBs in athletes and a stepwise diagnostic algorithm. The clinical work-up should include the assessment of the probable site of origin based on the ECG pattern of the ectopic QRS and of the arrhythmia behavior (including the number of different PVB morphologies, complexity, response to exercise and reproducibility), as well as first-line tests such as echocardiography. Based on this initial evaluation, most athletes can be reassured of the benign nature of PVBs and cleared for competition under periodical follow-up. However, when the clinical suspicion is high, further investigations with non-invasive (e.g. cardiac magnetic resonance, cardiac computed tomography, genetic testing) and, in very selected cases, invasive (e.g. endocardial voltage mapping and endomyocardial biopsy) tests should be carried out to rule out a high-risk condition. Importantly, such advanced tests should be performed in centers with a consolidated experience not only in the technique, but also in evaluation of athletes.

Low QRS voltages and left ventricular hypertrophy: a risky association

AIMS

Low QRS voltages (LQRSV) are an unexpected finding in left ventricular hypertrophy, i.e. hypertrophic cardiomyopathy (HCM) or athlete's heart.

METHODS AND RESULTS

Prevalence and clinical correlates of LQRSV were investigated in 197 consecutive HCM patients, aged 58 ± 13 years and comparatively in 771 Olympic athletes, aged 23 ± 4. Clinical characterization included family/personal history, symptoms, New York Heart Association (NYHA) functional class, electrocardiographic pattern, ventricular arrhythmias, and cardiac magnetic resonance (CMR). Twenty-two (11%) of HCM and 18 (2.3%) of athletes presented LQRSV. At initial evaluation, in HCM, LQRSV showed no differences vs. non-LQRSV for functional class (90% vs. 91%, in Classes I and II; P = 0.983), symptoms (27% vs. 18%; P = 0.478), and ventricular arrhythmias (40% vs. 39%; P = 857) but showed larger extent of late gadolinium enhancement (LGE) at CMR (4.1 ± 1.5 vs. 1.5 ± 0.7 affected segments; P < 0.001). In athletes, LQRSV was associated with larger prevalence of inverted T-waves (22% vs. 9%; P < 0.001) and ventricular arrhythmias (28% vs. 8%; P = 0.005). In one LQRSV athlete, arrhythmogenic cardiomyopathy was identified. Over 4.5 ± 2.6-year follow-up, presence of LQRSV in HCM was associated with larger incidence of functional deterioration (31% vs. 14%; P = 0.038), stroke (22% vs. 6%; P = 0.008), and implantable cardioverter defibrillator (ICD) implant (27% vs. 10%; P = 0.015). No clinical events occurred in LQRSV athletes without initial evidence of cardiac disease.

CONCLUSION

LQRSV are relatively common (11%) in HCM and have clinical relevance, being predictive over a medium term for a worsening functional class, incidence of stroke, and ICD implant. Instead, LQRSV are rare (2.3%) in athletes but may occasionally be a marker that raises suspicion for underlying cardiac disease at risk.

Aortic Root Diameter in Highly-Trained Competitive Athletes: Reference Values According to Sport and Prevalence of Aortic Enlargement

BACKGROUND

Studies exploring the extent of aortic root dilation across the different types of sport are limited. We aimed to define the physiological limits of aortic remodelling in a large population of healthy elite athletes in comparison with nonathletic controls.

METHODS

A total of 1995 consecutive athletes evaluated at the Institute of Sports Medicine (Rome, Italy) and 515 healthy controls underwent a comprehensive cardiovascular screening. The aortic diameter was measured at the level of the sinuses of Valsalva. The 99th percentile from the mean of the aortic diameter in the control population was used to define an abnormally enlarged aortic root dimension.

RESULTS

Athletes showed a larger aortic root diameter (30.6 [± 3.3] vs 28.1 [± 3.1] mm, P value < 0.001) than controls. The difference was evident in male and female athletes, regardless of sport- predominant component and level of intensity. The 99th percentile value for aortic root diameter in control male and female subjects was 37 mm and 32 mm, respectively. Based on these values, 50 (4.2%) male and 21 (2.6%) female athletes would have been diagnosed with an enlarged aortic root. However, aortic root diameter of clinical relevance-ie, ≥ 40 mm-was observed in only 17 male athletes (0.85%) and did not exceed > 44 mm.

CONCLUSIONS

Athletes show a mild, although significant, increased aortic dimension in comparison with healthy controls. The degree of aortic enlargement varies in relation to type of sports and sex. Eventually, only a small minority of athletes exhibited a markedly enlarged aortic diameter (ie, ≥ 40 mm) in a range of clinical relevance.

Electroanatomic mapping in athletes: Why and when. An expert opinion paper from the Italian society of sports cardiology

Three-dimensional electroanatomical mapping (EAM) has the potential to identify the pathological substrate underlying ventricular arrhythmias (VAs) in different clinical settings by detecting myocardial areas with abnormally low voltages, which reflect the presence of different cardiomyopathic substrates. In athletes, the added value of EAM may be to enhance the efficacy of third-level diagnostic tests and cardiac magnetic resonance (CMR) in detecting concealed arrhythmogenic cardiomyopathies. Additional benefits of EAM in the athlete include the potential impact on disease risk stratification and the consequent implications for eligibility to competitive sports. This opinion paper of the Italian Society of Sports Cardiology aims to guide general sports medicine physicians and cardiologists on the clinical decision when to eventually perform an EAM study in the athlete, highlighting strengths and weaknesses for each cardiovascular disease at risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression, and worsening of the arrhythmogenic substrate is also addressed.

Determinants of LV mass in athletes: the impact of sport, constitutional traits and cardiovascular risk factors

BACKGROUND

Whether cardiovascular (CV) risk factors might impact Left Ventricular (LV) mass in athletes is unknown.

METHODS

The impact of CV risk factors (Total/LDL cholesterol, triglycerides, positive family history, smoking, body fat, blood pressure), constitutional characteristics (age, sex, body mass index) and type of sport was assessed in 1111 Olympic athletes.

RESULTS

Multivariate logistic regression analysis demonstrated a significant impact: BMI ≥ 30 kg/m² (odds ratio [OR] = 2.8. 95° Confidence Interval [CI] 0.9-13.7; < 0.001; in males); age ≥ 20-year (OR = 2.1, CI 1.4-3.3; p < 0.001) in males; (OR = 2.3; CI 1.4-3.7) in females; systolic blood pressure ≥ 130 mmHg (OR = 1.1, CI 1.01-1.16; p < 0.001) in males; (OR = 1.03; CI 1.01-1.06; p < 0.03) in females; diastolic ≥ 85 mmHg (OR = 1.1, CI 1.03-1.2; p = 0.003) in males; (OR = 1.05, CI 1.02-1.08, p < 0.001) in females. No association was found for family history, smoking, body fat, LDL, total cholesterol, triglycerides. Overall, constitutional traits explain > 60% of the LV mass. Sport explains on average 14%, but large differences existed among disciplines, i.e., endurance showed the highest impact (55%, mixed: 20%, power: 17%, skill: 8%; p < 0.001).

CONCLUSION

LV mass in athletes is largely governed by constitutional traits and type of sport, and independent from CV risk factors, except for systolic and diastolic blood pressure. Overall, constitutional traits explain more than 60% of LV mass. The impact of sport is largely different in relation to the discipline, and highest in endurance, moderate mixed and power and mild in skill disciplines.

Reversible Apical Hypertrophy in a Young Competitive Athlete with Familiar Hypertrophic Cardiomyopathy

BACKGROUND Differential diagnosis between athlete's heart and hypertrophic cardiomyopathy is sometimes challenging in sport cardiology since endurance training can cause a distinct pattern of functional and structural changes of the cardiovascular system. It is of crucial importance to accurately diagnose it and stratify the arrhythmic risk since hypertrophic cardiomyopathy is one of the leading causes of sudden cardiac death in young athletes. Apical hypertrophic cardiomyopathy is a relatively rare form of hypertrophic cardiomyopathy that predominantly affects the apex of the left ventricle and usually has a nonobstructive physiology. Few data and studies are available on influence of aerobic training (and detraining) on morphological changes in athletes with apical hypertrophic cardiomyopathy. CASE REPORT We present the case of a 19-year-old male soccer athlete with family history for obstructive hypertrophic cardiomyopathy, with electrocardiographic and morphological left ventricular remodeling in association with sports activity. Intensive aerobic training led to marked T-wave inversion on 12-lead ECG and left ventricular hypertrophy compatible with apical hypertrophic cardiomyopathy. Genetic testing confirmed the presence of familial variant c853C>T, p.(Arg 285Cys) on TNNT2 gene. After 18 months detraining, we observed a complete regression of ECG abnormalities and a reverse remodeling of the left ventricular hypertrophy. No pharmacological therapy was indicated; periodic cardiological evaluations were advised. Monitoring devices or implantable cardioverter defibrillator were not recommended. CONCLUSIONS This case suggests that intensive aerobic training can affect the pathological hypertrophic cardiomyopathy substrate, facilitating the development of left ventricular hypertrophy and, more interesting, regression of structural changes after detraining.

Leisure-time and competitive sport participation: a changing paradigm for HCM patients

HCM has long been considered the most frequent cause of death in athletes, and reason for disqualification from sport. However, our perception of the impact of sports on HCM is largely based on anecdotal evidence. In this review, we provide a reappraisal of current knowledge relative to 1) the impact of sport on LV remodeling, and 2) on the clinical outcome of HCM in athletes. 1) The limited available evidence argues against the hypothesis that intensive exercise conditioning may trigger and/or worsen the development of LV hypertrophy or cause changes in LV function in adult HCM athletes. 2) Recent observations challenge the concept of a detrimental effect of sport on HCM clinical course. The Reset-HCM study showed that 16-week moderate-intensity exercise resulted in a small, significant increase in exercise capacity and no adverse events. In a cohort of 88 low-risk HCM athletes followed for a 7-year period, survival analyses showed no difference in mortality between HCM who discontinued or pursued vigorous exercise programmes. Further reassurance was provided by the ICD Sports Safety Registry. Clinical implications: At present, patients' attitude to sport participation is highly variable, based on social and legal backgrounds surrounding medical practice in different countries. The shared-decision-making as suggested by current US and European guidelines allows the physician to deliver a tailored and more liberal advice. Physicians should be aware of the changing paradigm relative to exercise and sport prescription for HCM and promote active lifestyle as an integral component of modern management of HCM patients.

Low prevalence of cardiac abnormalities in competitive athletes at return-to-play after COVID-19

OBJECTIVE

to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes at return-to-play (RTP) evaluation, following the recommended Italian protocol including cardiopulmonary exercise test (CPET) and 24-Hour Holter monitoring.

DESIGN AND METHODS

this is a single centre observational, cross-sectional study. Since October 2020, all competitive athletes (age ≥ 14 years) evaluated in our Institute after COVID-19, prior RTP were enrolled. The protocol dictated by the Italian governing bodies included: 12‑lead ECG, blood test, CPET, 24-h ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication.

RESULTS

219 consecutive athletes were examined (59% male), age 23 years (IQR 19-27), 21% asymptomatic, 77% mildly symptomatic, 2% with previous pneumonia. The evaluation was performed after a median of 10 (6-17) days from negative SARS-CoV-2 swab. All athletes showed a good exercise capacity at CPET without cardiovascular and respiratory limitations. Uncommon premature ventricular contractions (PVCs) were found in 9.5% (n = 21) at CPET/Holter ECG monitoring. Two athletes (0.9%) were diagnosed with acute myocarditis (by CMR) and another one with new pericardial effusion. All the three athletes were temporally restricted from sport participation.

CONCLUSIONS

Myocarditis in competitive athletes screened after COVID-19 resolution was detected in a low minority of the cases (0.9%). However, a non-negligible prevalence of uncommon PVCs (9%) was observed, either at CPET and/or Holter ECG monitoring, including all athletes with COVID-19 related cardiovascular abnormalities.

Molecular genetic testing in athletes: Why and when a position statement from the Italian society of sports cardiology

Molecular genetic testing is an increasingly available test to support the clinical diagnosis of inherited cardiovascular diseases through identification of pathogenic gene variants and to make a preclinical genetic diagnosis among proband's family members (so-called "cascade family screening"). In athletes, the added value of molecular genetic testing is to assist in discriminating between physiological adaptive changes of the athlete's heart and inherited cardiovascular diseases, in the presence of overlapping phenotypic features such as ECG changes, imaging abnormalities or arrhythmias ("grey zone"). Additional benefits of molecular genetic testing in the athlete include the potential impact on the disease risk stratification and the implications for eligibility to competitive sports. This position statement of the Italian Society of Sports Cardiology aims to guide general sports medical physicians and sports cardiologists on clinical decision as why and when to perform a molecular genetic testing in the athlete, highlighting strengths and weaknesses for each inherited cardiovascular disease at-risk of sudden cardiac death during sport. The importance of early (preclinical) diagnosis to prevent the negative effects of exercise on phenotypic expression, disease progression and worsening of the arrhythmogenic substrate is also addressed.

Left ventricle myocardial deformation in olympic athletes assessed by cardiac magnetic resonance: does the sex and discipline matter?

Funding Acknowledgements

Type of funding sources: None.

Background

Sport induces structural and functional cardiac adaptation with different entity related to several factors including type of training and gender. Cardiovascular Magnetic Resonance (CMR) is the gold standard for morpho-functional evaluation of athletes’ heart and commonly relies on ventricular volume, wall thickness and ejection fraction (EF) assessment. Data on myocardial deformation (MD) are limited to echocardiography and are scarce.

Purpose

To assess MD in Olympic athletes and to evaluate the possible influence of sport categories and gender.

Methods

A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed for volume and function evaluation and to assess global longitudinal strain (GLS) and global circumferential strain (GCS) by feature-tracking software. Athletes were divided in subgroups according to ESC sport classification. Male and female athletes were compared. Athletes were also divided based on EF (≤53% or &gt;53%).

Results

93 elite athletes (33% power, 33% mixed, 33% endurance) and 18 controls were enrolled. No differences in terms of EF were observed, while endurance athletes showed the greater LV remodeling (Table). GLS and GCS values of the entire population were -22.5±2.7% and -30.7±3.4%, respectively. No significant differences were found comparing athletes of different sport categories and sedentary controls for GLS (p= 0.940) and GCS (p=0.072). Female athletes showed higher GLS compared to male (-23.5±2.8% vs-21.9±2.8%, p=0.002) but not differences in terms of GCS (-31.5±3.1% vs-30.2±3.5%, p=0.076). Athletes with EF≤53% had lower GLS values compared with those with &gt;53% but within normal limits (Figure).

Conclusion

No differences were observed in MD assessed by CMR between different sport categories and controls. Female athletes showed higher longitudinal but not circumferential strain compared with male. Athletes with lower EF presented lower values of strain but within normal range with the potentiality to be used as a tool for differential diagnosis between normal adaptation and disease.

Cardiovascular screening in olympic athletes before and after SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, these data are mainly based on Troponin and imaging findings.

Purpose

Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program.

Methods

Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation.

Results

Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, 4% had pneumonia. The evaluation was performed after a median of 9 days from negative SARS-CoV-2 swab. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes, however, only 6% (n=3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had mild pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR (Figure).

Conclusions

Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in presence of symptoms and elevated biomarkers). No one of the remaining athletes had abnormalities by imaging or laboratory test. Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears not justified.

Hemodynamic forces in olympic athletes assessed by cardiac magnetic resonance: a new non-invasive screening tool?

Funding Acknowledgements

Type of funding sources: None.

Background

Non-invasive evaluation of left ventricular hemodynamic forces (HDFs) by Cardiac Magnetic Resonance (CMR) is a promising tool to improve systolic and diastolic evaluation. No data are available on athletic population.

Purpose

To provide the range of normal values of HDFs in Olympic athletes and to evaluate the possible influence of different sport categories.

Methods

A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed by a feature-tracking based software to estimate HDFs. HDFs were measured in apex-base (AB) and latero-septal (LS) directions, over the entire heartbeat, in systole and diastole. Athletes were divided in subgroups according to ESC sport classification for comparison. They were also divided according to the ejection fraction (EF ≤ or &gt;53%).

Results

93 elite athletes (33% power, 33% mixed, 33% endurance) were enrolled. HDFs in AB and LS direction were 20.5%± 4.3 and 2.9%± 0.7 in the entire heartbeat, 32.6% ± 7 and 3.6%± 1 in systole, 11%± 4.1 and 2.3%± 0.8 in diastole. Comparing athletes of different sport category and sedentary controls no significant differences were found between groups (Table). Comparing athletes with ejection fraction (EF) £ 53% and &gt; 53%, the former showed lower values of AB-HDFs assessed in the entire heartbeat and in systole (18.9 ± 4.6 % vs 20.9 ± 4.1; p= 0.024 and 29.6 ± 6.3 vs 33.3 ± 7; p= 0.024, respectively), but within the normal range.

Conclusion

We provide normal range for HDFs assessed by CMR in elite athletes and no differences were observed between sedentary controls and athletes involved in different sport categories. Comparing athletes with low-normal and normal ejection fraction, the former showed lower values of AB-HDFs but within the normal range.

Low prevalence of cardiac abnormalities in competitive athletes before the return-to-play after COVID-19 based on the italian strategy

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, data are limited to the approached based on Troponine, ECG and echocardiogram while the data on exercise test are scarce.

Purpose

Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes for the RTP applying a comprehensive cardiovascular evaluation.

Methods

Since October 2020, all consecutive competitive athletes (age≥14 years) presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication.

Results

219 competitive athletes were enrolled (59% male), age 23 years (19,27): 20% asymptomatic, 77% mildly asymptomatic, 2% had pneumonia. The evaluation was performed after a median of 10 days (6-17 days) from negative SARS-CoV-2 swab. All athletes had a good performance at CPET. Uncommon premature ventricular contractions (PVCs) were found in 10% (n=21) and were detected by CPET. Two athletes (1%) were finally diagnosed with acute myocarditis (confirmed by CMR) and another had newly diagnosed mild pericardial effusion (Figure). All the three athletes were temporally refrain from sport participation.

Conclusions

Cardiac abnormalities in competitive athletes screened after COVID-19 resolution were detected in a minority of the cases (1.4%). No one of the remaining athletes had abnormalities by imaging or laboratory test neither reduction in cardiopulmonary fitness. Our data are in line with those reporting low prevalence of cardiovascular complication in mildly symptomatic or symptomatic athletes.

Positive CMR findings are associated with polymorphic ventricle arrhythmias and ECG repolarization changes but not with exercises induced arrhythmias in competitive and non-competitive athletes

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) provides an effective contribution for the prevention of sudden cardiac death with its ability to provide accurate information on morpho-functional abnormalities and on myocardial tissue characterization. However, data on its utility in clinical scenario in the competitive athletes are limited to selected cohort of patients with complex arrhythmias.

Objective

To retrospectively analyze all the CMR performed at our center for evaluating the predictors of positive CMR findings in a large cohort of competitive and non-competitive athletes presenting with different clinical indications.

Methods

Over a period of 30 months all the CMR performed on athletes aged &gt; 14 years and training for at least 5 hours per week at our Institutes were retrospectively recruited. The following data were also collected: medical history, ECG, echocardiography, exercise testing. CMR were categorized as "positive" or "negative" based on the presence or absence of late gadolinium enhancement (LGE, excluding RV insertion point) and/or morphological and/or functional abnormalities. Predictors of "positive" CMR were explored.

Results

503 CMR were recruited and the most frequent indications for CMR were: ventricular arrythmias (n= 213, 42%), ECG abnormalities (n= 140, 28%) followed by echocardiogram abnormalities, symptoms and family history (Figure A). 308 (61%) CMR were "negative" and 195 (39%) "positive" (Figure B). Uncommon ventricular arrythmias did not result associated with positive CMR (p= 0.43), while polymorphic ventricular beats are associated with positive CMR (p= 0.02). Among ECG abnormalities only T-waves inversion, particularly on lateral and infero-lateral leads, were associated with positive CMR (p= 0.04).

Conclusion

Ventricular arrhythmias represented the most common indication for require a CMR but in almost half the cases, the CMR was negative. Excises induced ventricular arrhythmias is not significantly associated with pathological findings on CMR, while the polymorphic morphology of arrhythmias and the presence of lateral and infero-lateral repolarization abnormalities on ECG were associated with positive CMR.

Prevalence and clinical significance of isolated low QRS voltages in young athletes

AIMS

Low QRS voltages (peak to peak <0.5 mV) in limb leads (LQRSV) on the athlete's electrocardiogram (ECG) may reflect an underlying cardiomyopathy, mostly arrhythmogenic cardiomyopathy (ACM) or non-ischaemic left ventricular scar (NILVS). We studied the prevalence and clinical meaning of isolated LQRSV in a large cohort of competitive athletes.

METHODS AND RESULTS

The index group included 2229 Italian competitive athletes [median age 18 years (16-25), 67% males, 97% Caucasian] without major ECG abnormalities at pre-participation screening. Three control groups included Black athletes (N = 1115), general population (N = 1115), and patients with ACM or NILVS (N = 58). Echocardiogram was performed in all athletes with isolated LQRSV and cardiac magnetic resonance (CMR) in those with ventricular arrhythmias or echocardiographic abnormalities. The isolated LQRSV pattern was found in 1.1% index athletes and was associated with increasing age (median age 28 vs. 18 years; P < 0.001), elite status (71% vs. 34%; P < 0.001), body surface area, and body mass index but not with sex, type of sport, and echocardiographic left ventricular mass. The prevalence of isolated LQRSV was 0.2% in Black athletes and 0.3% in young individuals from the general population. Cardiomyopathy patients had a significantly greater prevalence of isolated LQRSV (12%) than index athletes, Black athletes, and general population. Five index athletes with isolated LQSRV and exercise-induced ventricular arrhythmias underwent CMR showing biventricular ACM in 1 and idiopathic NILVS in 1.

CONCLUSIONS

Unlike cardiomyopathy patients, the ECG pattern of isolated LQRSV was rarely observed in athletes. This ECG sign should prompt clinical work-up for exclusion of an underlying cardiomyopathy.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology

Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.

Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2020

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Managing athletes with palpitations of unknown origin with an external loop recorder: a cohort study

BACKGROUND

Palpitations in athletes are usually benign, but the presence of major cardiac arrhythmias should be ruled out despite the infrequent appraisal of symptoms. External loop recorders (ELR) are promising to identify arrhythmias in these circumstances, but experiences in athletes are lacking. We aimed to investigate the feasibility and diagnostic yield of an ELR in athletes with unexplained palpitations in a cohort study.

METHODS

122 consecutive subjects (61 athletes and 61 sedentary controls) with sporadic palpitations and inconclusive diagnosis were enrolled and equipped with an ELR. Findings were categorized as major and minor arrhythmic findings, non-arrhythmic findings or negative monitoring.

RESULTS

Long-term ELR monitoring was feasible in all subjects, with median duration of 12 (11; 15) days. Major arrhythmic events during palpitations were found in 9 (14.8%) athletes: 7 experienced sustained paroxysmal supraventricular tachycardia, and 2 had non sustained ventricular tachycardia. Minor arrhythmic events (premature supraventricular or ventricular beats) were observed in 13 athletes (21.3%). Non-arrhythmic findings (i.e., sinus rhythm or sinus tachycardia) were recorded in 28 athletes (45.9%), whereas 11 (18%) had negative monitoring. In the sedentary group, arrhythmic events were similar for types and frequency to athletes. The diagnostic yield of loop monitoring was 82.8% in the overall population and 82.0% in the athlete's group.

CONCLUSIONS

In the management of an athlete symptomatic with unexplained palpitations after 24-hour ECG monitoring and stress test, ELR is an efficient tool to identify major arrhythmic events, which can be present in up to 10% of symptomatic athletes during practice and competition.

Clinical correlates and outcome of the patterns of premature ventricular beats in Olympic athletes: a long-term follow-up study

BACKGROUND

The pattern of premature ventricular beats, as a clue to site of origin, may help identify underlying cardiac diseases.

AIM

To assess the value of premature ventricular beat patterns in managing athletes with ventricular arrhythmias.

METHODS

Athletes with 50 or more isolated premature ventricular beats/24 hours, and/or multifocal and/or repetitive premature ventricular beats at baseline, and/or exercise, and/or 24-hour electrocardiograms were selected for this analysis. Premature ventricular beats were defined as 'common' (outflow tract or fascicular origin), or 'uncommon' (other morphologies and/or multifocal or repetitive).

RESULTS

From 4595 athletes consecutively examined, 205 (4%, 24.6 ± 6.9 years, 67% men) were included, 118 (58%) with uncommon and 87 (42%) with common premature ventricular beats. In particular, 81 (39%) showed complex patterns; 63 (31%) right/left ventricular outflow tract origin; 24 (12%) fascicular origin; 20 (10%) right bundle branch block pattern, intermediate/superior axis, wide QRS; and 17 (8%) left bundle branch block pattern, intermediate/superior axis. Uncommon premature ventricular beat patterns were predominant among men (62% vs. 38%; P < 0.001) but not among women. Uncommon premature ventricular beats were equally prevalent in endurance, mixed and skill disciplines, but lower in power sports. Cardiac diseases were detected in 11 (5%), 10 with uncommon patterns. Over a 6-year follow-up, cardiac diseases occurred in four (0.6%/year), all with uncommon patterns. Overall, cardiac diseases at baseline and during follow-up were detected in 14/118 athletes with uncommon versus one/87 with common premature ventricular beats (P = 0.003).

CONCLUSIONS

Evaluation of premature ventricular beat patterns in Olympic athletes identified cardiac diseases, requiring disqualification and/or follow-up, in 12% with uncommon versus 1% with common patterns. This result suggests that athletes with uncommon premature ventricular beat patterns should undergo comprehensive cardiac evaluation and/or serial follow-up, irrespective of gender or sporting discipline.

Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators

This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.

2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease

The Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC)

Natural history of right ventricle: longitudinal study in veteran athletes

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Right ventricular (RV) enlargement is a physiologic adaptation to long lasting athletic training. Its clinical implications for veteran athletes are poorly understood. In recent years, controversial data suggest an association between ultra-endurance exercise and a RV cardiomyopathy similar to arrhythmogenic cardiomyopathy (ACM). In this context, the effects of exercise detraining have not been extensively studied yet.

PURPOSE

The aim of this study was to assess the morphological and functional RV changes in veteran athletes and to evaluate the effect of a long period of detraining.

METHODS

This is a longitudinal study including 22 veteran rowers with at least 10 years of competitive career. We evaluated them with an echocardiographic assessment at baseline and after a minimum of 3 years of detraining (age: 23.2 ± 4.4 and 43 ± 7.4 years), by reducing the weekly training volume from 26 ± 0.7 to 3 ± 2 hours. In this second evaluation we also performed an RV strain analysis and a cardiac magnetic resonance (CMR) study.

RESULTS

RV end diastolic (ED) areas significantly reduced after detraining (31.48 ± 5.8 versus 28.59 ± 6.8; p = 0.001), although remaining larger than normal. RV enlargement was balanced: the ratio between inflow (IT) and outflow tract (OT) (RVIT/RVOT = 1.4 ± 0.1) and the ratio between RV and left ventricle (LV) (RV/LV = 0.81 ± 0.1) were within normal limits. The fractional area change (FAC%) was normal at baseline and increased significantly (41.5 ± 6% versus 45.8 ± 7%; p = 0.011). After detraining, RV longitudinal strain was normal (-19.7 ± 2.7%). CMR assessment showed enlarged RVED volumes (97.9 ± 14 ml/m2) but normal RV ejection fraction (55.5 ± 4.1%).

CONCLUSIONS

RV enlargement in endurance athletes persists after a long period of detraining. However, detraining results in a significant reduction of RV dimensions. Furthermore, the absence of RV dysfunction or disproportionate RV geometry are reassuring findings that suggest a physiological remodeling of the RV.

Significant echo findings. RV ECHO PARAMETERS BASELINE DETRAINING MEAN DIFF. (C.I. 95%) p VALUE RVOT plax (mm) 34.8 ± 4 33.7 ± 14 1.1 (0.18; 2.1) p = 0.011 RVOT psax (mm) 34.9 ± 3.3 33.09 ± 3.5 1.8 (0.9; 2.7) p &lt; 0.001 RV basal diameter (mm) 47.31 ± 5.3 45.86 ± 6.4 1.4 (0.04; 2.8) p = 0.022 RV end-diastolic area (cm&sup2;) 31.48 ± 5.8 28.59 ± 6.8 2.8 (1.1; 4.6) p = 0.001 FAC% 41.5 ± 6 45.8 ± 7 0.04 (-0.07; -0.007) p = 0.011 RV inflow/outflow ratio 1.36 ± 0.1 1.36 ± 0.2 -0.003 (-0.06; 0.06) p = 0.454 RV/LV ratio 0.82 ± 0.07 0.81 ±0.1 0.01 (-0.01; 0.04) p = 0.219

Abstract Figure. Comparison in the same veteran athlete.

Recommendations for participation in competitive sport in adolescent and adult athletes with Congenital Heart Disease (CHD): position statement of the Sports Cardiology & Exercise Section of the European Association of Preventive Cardiology (EAPC), the European Society of Cardiology (ESC) Working Group on Adult Congenital Heart Disease and the Sports Cardiology, Physical Activity and Prevention Working Group of the Association for European Paediatric and Congenital Cardiology (AEPC)

Improved clinical care has led to an increase in the number of adults with congenital heart disease (CHD) engaging in leisure time and competitive sports activities. Although the benefits of exercise in patients with CHD are well established, there is a low but appreciable risk of exercise-related complications. Published exercise recommendations for individuals with CHD are predominantly centred on anatomic lesions, hampering an individualized approach to exercise advice in this heterogeneous population. This document presents an update of the recommendations for competitive sports participation in athletes with cardiovascular disease published by the Sports Cardiology & Exercise section of the European Association of Preventive Cardiology (EAPC) in 2005. It introduces an approach which is based on the assessment of haemodynamic, electrophysiological and functional parameters, rather than anatomic lesions. The recommendations provide a comprehensive assessment algorithm which allows for patient-specific assessment and risk stratification of athletes with CHD who wish to participate in competitive sports.