Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with premature ventricular complexes and implications for sports' eligibility assessment

Background

Premature ventricular complexes (PVCs) are a common clinical problem and a critical issue with regard to sports eligibility in sportsmen. Although PVCs can be considered a benign feature of the athlete's heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity. The optimal diagnostic evaluation of athletes with PVCs is currently uncertain.

Purpose

To evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with PVCs.

Methods

We conducted a prospective, single-arm, open-label double center study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to PVCs were included in our study. These athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently, an invasive diagnostic work-up was performed, including EPS with programmed electrical stimulation, EAM and EAM-guided EMB if deemed necessary. When clinically indicated, catheter ablation was performed. Sports eligibility status was re-assessed at six months' follow-up according to Italian sports medicine guidelines.

Results

After diagnostic evaluation, 20 subjects out of 107 (19%) had a diagnosis of heart disease, most commonly myocarditis (n=8), arrhythmogenic right ventricular cardiomyopathy (ARVC, n=7) or dilated cardiomyopathy (DCM, n=2). On multivariate logistic-regression analysis, QRS complex/T wave abnormalities on ECG (OR 23), non left bundle branch block and inferior axis PVC morphology (OR 13), echocardiogram abnormalities (OR 24) and low-voltage areas on EAM (OR 33) were significantly associated with diagnosis of a concealed cardiac disease. Nondiagnostic abnormalities on cMRI were common in this population of athletes, prevalently involving the right ventricle. EAM-guided EMB was performed in 12 subjects (11%) and catheter ablation in 56 (52.3%). After six months, 63 athletes (59%) were judged eligible to participate in competitive sports and 23 subjects (21%) were deemed eligible to participate in non-competitive sports.

Conclusions

Almost one fifth of sportsmen presenting with PVCs have a concealed heart disease, most commonly myocarditis or ARVC. Non-outflow tract PVCs' morphology and abnormalities on ECG, echocardiogram and EAM are predictive of structural heart disease's detection, whereas nondiagnostic findings on cMRI can be misleading in athletes. Invasive diagnostic tests, including EAM and EAM-guided EMB, play a critical role in case of diagnostic uncertainty. More than ¾ of subjects were judged eligible to participate in sports at 6 months' follow-up.

Funding Acknowledgement

Type of funding source: None

Atrial fibrillation ablation in athletes: 5-years experience of a single italian third-level center

Background

The number of master athletes is increasing and treatment of AF is mandatory for sports continuation. However, few data exist about the effectiveness of catheter ablation (CA) in athletes and the feasibility of resuming vigorous exercise afterwards.

Objectives

Aim of our study was to analyze the efficacy and safety of AF CA in athletes and to evaluate the feasibility of resuming vigorous exercise.

Methods

We report a retrospective registry of athletes referred to our center for AF CA in the last five years. All athletes were previously declared non-eligible to competitive sport because of recurrences of AF or evidence of persistent asymptomatic AF. CA was performed as per practice and recurrences were defined as recrudescence of symptoms and/or any documentation of AF lasting more than 30 sec. At the end of the follow-up all pts were asked about resuming sport.

Results

We ablated 40 athletes (38 males, 95%) with a mean age of 48±13 years. Mean left atrium volume was 36±11 ml/m2 and mean ejection fraction was 61±5%. Distribution between AF characteristics was: 31 (78%) paroxysmal AF, 8 (20%) early-persistent AF, 1 (2%) long-persistent AF.

After a median follow-up of 787 days, 62,5% of athletes were free from recurrences after one CA procedure and mostly without antiarrhythmic drugs (87%). 7 athletes underwent a redo procedure and all of them were then free of recurrences with an overall freedom from recurrences of 84%. No major complication was observed. Athletes practicing endurance sports showed a negative trend in terms of recurrences (p = ns).

Most (72%) of the athletes resumed vigorous exercise after at least 3 months from the CA as per Italian sport protocols.

Conclusions

CA is safe and efficient in treating AF also in athletes. Resuming high intensity sports is often possible after 3 months from CA.

Funding Acknowledgement

Type of funding source: None

P1110Role of an extensive diagnostic work-up in the detection of concealed cardiomyopathies in athletes with complex ventricular arrhythmias and implications for sports" eligibility assessment

Background

ventricular Arrhythmias (VAs) are a common clinical problem and a critical issue with regards to sports" eligibility in athletes. Although VAs can be considered a benign feature of the athlete’s heart adaptive phenotype, they may also be the only clinical manifestation of a concealed cardiomyopathy, potentially heralding sudden cardiac death (SCD) during sports activity.

Purpose

to evaluate the diagnostic contribution and the implications for sports eligibility assessment of a thorough non-invasive and invasive work-up including electrophysiology study (EPS), electroanatomical mapping (EAM) and endomyocardial biopsy (EMB) in athletes with complex VAs and to derive a multiparametric risk score in order to easily predict structural heart diseases’ diagnosis.

Methods

we conducted a prospective, single-arm, open-label single center, observational study. All consecutive athletes presenting for evaluation at our institution after being disqualified from participating in sports due to complex VAs were enrolled. The athletes underwent a baseline non-invasive diagnostic protocol with transthoracic echocardiogram and gadolinium enhanced cardiac magnetic resonance imaging (cMRI). Subsequently EPS, EAM and EAM-guided EMB were performed if deemed necessary. Sports eligibility status was re-assessed at 6 months’ follow-up. A multivariable logistic regression model was built, considering cMRI as the gold standard exam.

Results

after diagnostic evaluation, 55 subjects (26.4%) had a diagnosis of heart disease, most commonly myocarditis (n = 27) and arrhythmogenic right ventricular cardiomyopathy (ARVC, n = 16). After 6 months, 100 athletes (48.1%) were judged eligible to participate in competitive sports and 46 subjects (22.1%) were deemed eligible to participate in non-competitive sports. On multivariable logistic-regression analysis, abnormalities on ECG (OR 5.3) or on echocardiogram (OR 3.7), sustained VA inducibility on EPS (OR 17.7) and low-voltage areas on EAM (OR 7.7) proved all predictive of concealed structural heart diseases’ diagnosis. We derived two simple risk scores: a 40-points risk score and an 8-points risk score (obtained by weighing each variable according to the regression model’s ORs). Both these risk scores’ performance proved very good (AUC = 0.856 for the 40-points score and AUC = 0.852 for the 8-points score, figure 1).

Conclusions

approximately 1/4 of athletes presenting with complex VAs have a concealed heart disease, most commonly myocarditis or ARVC. ECG, echocardiogram and EAM abnormalities and sustained VAs inducibility on EPS are predictive of structural heart diseases’ detection. Therefore, these diagnostic tests should be routinely included in the evaluation of athletes with complex VAs. A risk score including the results of these tests can greatly help in the prediction of concealed structural heart diseases’ diagnosis. More than 2/3 of subjects were judged eligible to participate in sports at 6 months’ follow-up.

Abstract Figure 1. ROC curves for diagnosis

P485Re-interpretation of variants of uncertain significance in inherited cardiovascular diseases-A pilot study

Background- Identification of variants of uncertain significance (VUSs) poses relevant challenges in counseling and managing patients. They have an unknown impact on health, making the genetic tests clinically irrelevant. Recent studies demonstrate that a routine reclassification analysis enables to reclassify from 20% to 80% of this type of variant, improving risk stratification.

Purpose- We investigated whether, in the context of inherited cardiac conditions, a review of the updated literature, including new functional data, allele frequency (GnomAD) and segregation analysis may help in the variant reclassification.

Methods- Retrospective review of all VUSs in genes associated with inherited cardiac conditions identified in our cardiogenetic clinic between 2016 and 2018.

Results- Thirty-one VUSs, classified using ACMG guidelines, were identified in 26 cases with a confirmed or suspected diagnosis of inherited cardiovascular diseases, including Long QT syndrome, Brugada syndrome, Arrhythmogenic Cardiomyopathy and Hypertrophic Cardiomyopathy). Twentyfour variants were identified in well-defined causative genes (SCN5A, KCNQ1, KCNH2, KCNE1, DSP, DSG2, MYH7, TPM1, TNNI3, TNNT2, CACNA1C, MYL3) while the remaining variants were identified in minor genes with limited evidence to support their disease causation as, ANK2 and AKAP9 gene. Preliminary results of the reclassification analysis showed that two variants were downgraded to likely benign (LB) applying the BS1 criterion (allele frequency) and 4 variants were upgraded to likely pathogenic (LP) according to novel published data and family segregation studies. Moreover, further studies to assess cosegregation in other variants are still ongoing.

Conclusion- Based on our experience, 25% of variants of uncertain significance in well-defined causative genes, identified in patients with a confirmed or suspected diagnosis of inherited cardiovascular disease, were reclassified. These findings suggest that re-evaluation of genetic test results should be performed routinely in all diagnostic labs, in order to improve risk stratification and identification of family members at high risk.

P4422Myocarditis: a deceitful but not infrequent athletes' enemy

Introduction

Myocarditis represents a not negligible cause of sudden death (SD) in athletes, representing the cause of 4%-14% cardiac arrests and deaths in athletes. Preparticipation screening including 12-leads basal electrocardiogram could drastically reduce SD in athletes and screening programs are therefore now recommended by most medical and sport association. At the moment, no data in literature are available about incidence of concealed myocarditis in athletes but there is general consensus about disqualification from competitive sport in the presence of myocardial fibrosis (MF).

Purpose

Purpose of our study was to quantify incidence of MF consistent with past myocarditis in athletes that referred to our Sport Cardiology Center for ventricular arrhythmias (VA) +/− repolarization abnormalities (RA) detected at preparticipation screening.

Methods

In our study we retrospectively evaluated all athletes with VA +/− RA and we quantified how many were found to have MF consistent with myocarditis at cardiac MRI. Furthermore, we evaluated characteristics of presentation in terms of clinical symptoms of myocarditis and frequency and morphology of VA. Finally, we analyzed findings of invasive diagnostic workout when performed.

Results

In the last two years we evaluated 111 athletes for VA +/− RA and we found MF consistent with myocarditis in 18 (16%) of them. Only 2/18 referred past febrile status probably correlated with myocarditis and 1 had symptoms consistent with acute myocarditis. Number of VA was not correlated with MF fibrosis, while polymorphic VA and exercise-correlated VA were the most frequent finding. 5/18 (28%) had also rest and/or exercise induced RA. 10/18 (55%) athletes underwent electrophysiological study without any induction of arrhythmias. 7/18 (39%) underwent also electroanatomical mapping (EAM) with pathological findings in 5/7 (71%). All of these 5 underwent endomyocardial biopsy guided by EAM and in 2 cases bioptic findings were consistent with arrhythmogenic cardyomyopahty (ACM). All 18 athletes were disqualified from competitive sport as for Italian Sport Medicine protocols.

Conclusion

MF consistent with past myocarditis is a not infrequent finding in athletes with VA with or without RA. Morphology and exercise behavior of VA are the most important “alarm bell”, while VA number is not correlated with MRI pathological findings. Sometimes MF interpreted as consistent with past myocarditis is actually the manifestation of ACM. Identification of these diseases is of extreme importance for athletes' safety.

P307Magnetic resonance, electroanatomical mapping, and endomyocardial biopsy to solve the diagnostic and sport eligibility dilemma in a cohort of competitive athletes with ventricular arrhythmias

Background

Ventricular arrhythmias (VAs) are a frequent finding in agonist athletes (athl) at routine sport medicine visits. VAs impact on sport eligibility, their management, and the sudden arrhythmic death risk evaluation in athletes currently represents one of the greatest challenges across both the cardiology and sport medicine field.

Purpose

To describe how an advanced multi-methodical evaluation allowed diagnosis, risk stratification, targeted therapy and sport eligibility reassessment in a competitive athl cohort with ventricular arrhythmias and pathological findings at magnetic resonance (MR).

Methods

All consecutive competitive athl with denied sport eligibility due to ventricular arrhythmias that underwent an advanced invasive evaluation at our institute were enrolled.

A baseline and stress ECG, and late gadolinium enhanced evaluation (LGE) at MR were performed prior to invasive evaluation in all athl.

Invasive evaluation performed in all athl comprised of an electrophysiological study (EPS) to assess arrhythmic inducibility, an endo-cavitary electro-anatomical mapping (EAM), and a EAM and MR guided endo-myocardial biopsy (EMB). A defined diagnosis was postulated in all cases, specific therapeutic interventions were started and sport eligibility status reassessed after 6 months from discharge.

Results

Thirty-two competitive athl were enrolled in our study (32±6 y.o.; 77% male; 4±1 1h-training session/week); 26 (81%) athl practiced a mixed aerobic-anaerobic, 5 (16%) a pure-aerobic, while only 1 (3%) a pure anaerobic sport.

Arrhythmic presentation leading to sport eligibility revoke was: in 13 (40%) athl frequent (>2000/day) premature ventricular contractions (PVCs) at rest, in 2 (6%) PVCs during stress ECG, in 6 (18%) non-sustained ventricular tachycardia (VT), in 8 (25%) sustained VT, and in 3 (11%) ventricular fibrillation/cardiac arrest during sport practice.

MR alterations were described in all cases, and LGE at MR was found in 31 (87%) athl; a definite radiological diagnosis was obtained in 13 (40%) athl.

A normal myocardium at EMB was found only in 3 (8%) pts; in 15 (45%) a leukocyte infiltrate pattern compatible with myocarditis, in 11 (39%) fibro-fatty replacement, in 2 (5%) a mitochondrial disease and in 1 (3%) a sarcoidosis were proven, and diagnosis were consequently postulated.

EPS showed complex VAs inducibility in 8 (25%) cases, while a trans catheter ablation was performed in 10 (31%) athl. A total of 9 (28%) implantable cardioverter devices (ICDs) were implanted, for primary or secondary prevention.

According to invasive diagnostic findings and sport medicine guidelines, 8 (25%) athl had their sport eligibility statuts re-instated.

Conclusion

An invasive multi-methodical assessment allowed in all cases to reach a diagnosis and to start a targeted therapy in a cohort of competitive athl with VA and a pathological MR, granting in a significant (25%) percentage sport eligibility status re-instatement.

Marked negative T waves in athletes: ECG normalization after detraining

Ventricular repolarization abnormalities (VRA) in athletes with apparently normal hearts, have always represented a challenging problem for sports physicians. We describe the case of an athlete with giant negative T waves and ST segment depression on resting electrocardiogram (ECG), "small" left ventricular cavity size and mild segmental hypertrophy at the echocardiogram (ECHO). After only 2 months of detraining, ECHO features were almost identical but ECG abnormalities disappeared. He has been followed in our Outpatient Clinic for 17 years, during which he had some cardiovascular complications, strongly suggestive of Hypertrophic Cardiomyopathy. At last stress test ECG, moreover, reappearance of VRA at high workloads and during the recovery period was documented. In conclusion, even if marked VRA disappear after a detraining period, we believe that they always represent a mark of an underlying disease and not just a sign of athlete's heart.

Lipid transfer proteins: the most frequent sensitizer in Italian subjects with food-dependent exercise-induced anaphylaxis

BACKGROUND

Specific food-dependent exercise-induced anaphylaxis (S-FDEIAn) is a distinct form of food allergy in which symptoms are elicited by exercise performed after ingesting food to which the patient has become sensitised. Non-specific FDEIAn (NS-FDEIAn) is a syndrome provoked by exercise performed after ingesting any food.

OBJECTIVE

We sought to identify the culprit allergenic molecules in patients with FDEIAn, combining 'classic' allergy testing with an allergenic molecule-based microarray approach for IgE detection.

METHODS

All subjects were evaluated who reported at least one episode of anaphylaxis in association with physical exercise performed within 4 h after a meal. We performed skin prick tests (SPT) with commercial food extracts, prick plus prick tests (P + P) with fresh foods (P + P), and serum specific IgE assays by means of both the ImmunoCAP (CAP) and the ISAC 89 microarray system (ISAC).

RESULTS

Among our 82 FDEIAn patients, the most frequent suspected foods were tomato, cereals, and peanut. SPT, P + P, and CAP displayed different degrees of sensitivity. Each test disclosed some positivities not discovered by others. Seventy-nine subjects were positive to at least one food (49 to more than 20), whereas three were negative. All suspected foods were positive to at least one of SPT, P + P, and CAP. When tested using the ISAC, 64 (78%) subjects were positive to Pru p 3 [peach lipid transfer protein (LTP)], 13 were positive to other food allergen molecules, and five displayed negative results to all food allergenic molecules. Overall, 79 patients probably had S-FDEIAn and the other 3 NS-FDEIAn.

CONCLUSIONS

Multiple food hypersensitivity represents a clinical hallmark of a large percentage of FDEIAn patients. The very high prevalence of IgE to the LTP suggests a role of this allergen group in causing S-FDEIAn.

Baseline simple and complex reaction times in female compared to male boxers

AIM

The aim of the study was to compare baseline cognitive performance of female in respect to male amateur boxers.

METHODS

Study population included 28 female amateur boxers. Fifty-six male boxers, matched for age, employment and competitive level to female athletes, formed the control group. All boxers had no history of head concussions (except boxing). Each boxer was requested to: 1) fulfill a questionnaire collecting demographic data, level of education, occupational status, boxing record and number of head concussions during boxing; 2) undergo a baseline computerized neuropsychological (NP) test (CogSport) measuring simple and complex reaction times (RT).

RESULTS

Female were lighter than male boxers (56±7 vs. 73.1±9.8 kg, P<0.0001). No significant differences at CogSport scores were observed between groups. Male boxers showed a longer simple-RT at the end of the NP battery than at the beginning (0.247±0.007 vs. 0.243±0.007 s, P=0.02), however, with a significant lower rate of mistakes (0.7±1.6 vs. 2.0±3.1%, P=0.005), observed also in the female group (0.5±1.1 vs. 2.2±3.0%, P=0.005). No boxing activity parameter (record, number of knock-outs, etc.) correlated with NP scores.

CONCLUSION

Female and male Olympic-style boxers have no (or minimal) differences in baseline cognitive performance. Further research with larger series of female boxers is required to confirm these findings.

Physiological characteristics of elite sport-dancers

AIM

Dancesport is increasing its popularity and it becomes to be considered as a real sport. Few studies are available about the physiological strain of dancesport competitions: moreover, recent changes in the official rules make it mandatory to revise our knowledge about the specific physiologic demands during competition. The aim of our study was to evaluate physiological parameters in top-level dancers.

METHODS

Twelve competitive dancesport couples (12 Latin-American and 12 Standard dancers) composed the study population. The first testing session was aimed at determining physical and physiological characteristics of athletes in laboratory; the second, at establishing physiological responses during simulated competition on field, involving the measurement of O(2) uptake (VO(2)), heart rate and blood lactate (BL).

RESULTS

Male dancers showed a peak-VO(2) of 60.9±6.0 and 59.2±7.0 mL/kg/min for Standard and Latin-American dancers, respectively. For females, peak-VO(2) was 53.7±5.0 mL/kg/min in Standard and 52.3±5.0 mL/kg/min in Latin-American dancers. During simulated competition, male dancers reached the 75.7±10.6 and 84.2±11.2% of peak-VO(2) (P<0.05) for Standard and Latin-American sequence, respectively. For females, no difference was observed (70.8±13.8% in Latin-American and 72.5±12.8% in Standard). Peak-BL during simulated Standard competition was 6.50±2.1 and 6.91±2.6 mM in males and females, respectively, and, for Latin-American sequence, 7.95±2.1 mM in males and 6.04±2.5 mM in females.

CONCLUSION

Dancesport can be defined as a sport discipline with an alternate physical activity with medium lasting and high energy-demanding (both aerobic and anaerobic) consecutive phases, separated by short recovery periods. These data must be kept into account while planning specific training programs in sportdancers.

[Sport and physical activity]

A regular sport activity involves physical and psychological benefits helping to improve the quality of life at any age. This aspect is even more important in the developing age, when the sport takes on a role of training and education. In this context, instances directed to allow adolescent and young adults with heart disease to practice sports seem justified, and they're becoming more pressing since when the diagnostic and therapeutic advances, especially in cardiac surgery and in interventional hemodynamics, allow an increasing number of patients, previously allocated to physical inactivity, to lead an active lifestyle. However, we have to keep in mind that congenital heart disease population is varied, not only by the nature of the malformation, but also because in the same cardiopathy you can find subjects in "natural history" or after surgery and, between them, subjects treated with several techniques and different outcomes. This justifies the need for a close collaboration between sports doctors, cardiologists and heart surgeons, particularly in the management of the most difficult and delicate problems.

Elite athletes: is survival shortened in boxers?

Moderate exercise and intense physical training are associated with increased life expectancy (LE). Boxing is characterized by intentional and repetitive head blows, sometimes causing brain injury, possibly reducing LE. We examined a sample of male athletes born between 1860 and 1930 selected from the international "hall of fame" inductees in baseball (n = 154), ice hockey (n = 130), tennis (n = 83), football (n = 81), boxing (n = 81), track and field (n = 59), basketball (n = 58), swimming (n = 37) and wrestling (n = 32). In boxing, we analyzed the number of disputed bouts/rounds and career records. Sports were also analyzed according to physiological demand and occurrence and kind of contact (intentional, unintentional). The Kaplan-Meier product limit method was used to compare survival curves (significance: p <or= 0.05). Median LE of the samples was 76.0 yrs and no differences were observed in different sports, although it was lower in boxers (73.0 yrs) and higher in tennis players (79.0 yrs). Sports of different physiological demand were similar in respect to LE. No differences in LE were found related to occurrence and kind of impact. Similar LE was found in boxers of different weight or career records. In conclusion, this study indicates that LE in top-level athletes is unaffected by the type of discipline, and not related to physiological demand and intentional contact.

Medical survey of female boxing in Italy in 2002-2003

BACKGROUND

Female boxing has been permitted in Italy since 2001. According to the latest Italian laws, athletes applying to become boxers have to pass a pre-participation medical examination.

OBJECTIVE

To collect novel medical information from the pre-participation visits and mandatory pre-competition and post-competition examinations for all fights involving Italian female boxers in 2002-2003.

METHODS

A retrospective study on all official female boxing competitions in Italy from January 2002 to October 2003 was conducted. A prospective study on 28 amateur female boxers was also carried out.

RESULTS

Retrospective study: data from 664 examinations were collected. Pre-match examinations were negative. After competitions, 19/645 visits showed some injuries, with mild, soft tissue facial lesions, epistaxis, and hand-wrist problems being the most common. Prospective study: no major lesions were found during the study. One fibroadenoma, one ovarian cyst, and one intramural uterine myoma were found. One boxer was referred to a neurologist because of non-specific electroencephalographic (EEG) abnormalities, which persisted six months later. On a re-admission examination, which was needed because of a contest that was stopped because the referee judged that she was receiving blows to the head that were dangerous, one boxer showed non-specific EEG alterations and nystagmus. A cerebral magnetic resonance imaging scan was normal. She was allowed to participate in competitions again when her EEG returned to normal and clinical signs disappeared. Deviation of the nasal septum was quite common (68%). No major eye injuries were reported.

CONCLUSION

Probably because of the correct preventive medical approach, female boxing is much safer than expected, and no major lesions (requiring hospital admission) were reported. Any lesions to the breast and reproductive system could not be considered to be boxing related.

Ocular complications of boxing

OBJECTIVES

To investigate the prevalence of ocular injuries in a large population of boxers over a period of 16 years, in particular, the most severe lesions that may be vision threatening.

METHODS

Clinical records of the medical archive of the Italian Boxing Federation were analysed. A total of 1032 boxers were examined from February 1982 to October 1998. A complete ophthalmological history was available for 956, who formed the study population (a total of 10 697 examinations). The following data were collected: age when started boxing; duration of competitive boxing career (from the date of the first bout); weight category; a thorough ocular history. The following investigations were carried out: measurement of visual acuity and visual fields, anterior segment inspection, applanation tonometry, gonioscopy, and examination of ocular fundus. Eighty age matched healthy subjects, who had never boxed, formed the control group.

RESULTS

Of the 956 boxers examined, 428 were amateur (44.8%) and 528 professional (55.2%). The median age at first examination was 23.1 (4.3) years (range 15-36). The prevalence of conjunctival, corneal, lenticular, vitreal, ocular papilla, and retinal alterations in the study population was 40.9% compared with 3.1% in the control group (p< or =0.0001). The prevalence of serious ocular findings (angle, lens, macula, and peripheral retina alterations) was 5.6% in boxers and 3.1% in controls (NS).

CONCLUSIONS

Boxing does not result in a higher prevalence of severe ocular lesions than in the general population. However, the prevalence of milder lesions (in particular with regard to the conjunctiva and cornea) is noteworthy, justifying the need for adequate ophthalmological surveillance.

Boxing and "commotio cordis": ECG and humoral study

The objective of the study was to analyze the presence of myocardial damage in relation to official boxing matches. Low-energy chest wall impact could be responsible for sudden cardiac death, i.e. commotio cordis. As boxing is a traumatic sport in which thoracic hits usually occur, it seems interesting to know if there are any significant cardiac changes during official bouts. Fifteen amateur boxers, participating in the semifinals of the Italian Championship were investigated. A standard ECG before, immediately after, 1 hour and 12 hours after the match were obtained from each athlete to analyze atrio-ventricular conduction, QRS axis and duration, and ventricular repolarization. A blood sample was also obtained before and 12 hours after the match for analysis of total-creatin-phosphokinase, myoglobin, and T-troponin. After the fight, the following significant changes were encountered: higher QRS voltages, lowering of J-point and ST segment in lateral leads, higher ST-slope, lower T-wave amplitude, shorter T-wave peak time, and shorter QT interval. When the last 2 parameters were corrected for heart rate, no differences were observed for QTc, while T-wave peak time significantly increased. All these changes persisted until one hour after the match. Moreover, 3/15 boxers (20 %) showed marked ventricular repolarization anomalies in lateral leads after the contest, persisting for 12 hours in one case. However, no athlete had clinical and humoral signs of myocardial damage following the match. It was concluded that no clinical and humoral signs of myocardial damage were found after amateur boxing matches, although ventricular repolarization abnormalities can be found on ECG in 20 % of boxers, probably due to sympathetic hyper-activity related to the agonistic event.

Prolonged Asystolia in a Young Athlete: A Case of Sinus Arrest During REM Sleep

A young asymptomatic male athlete came to our laboratory to be enrolled in a research protocol on physical fatigue. Routine clinical and cardiological evaluations including echocardiogram were in the normal range. Several consecutive cardiopulmonary tests showed a fairly good tolerance to exercise, with no symptoms even when the effort was abruptly arrested. On the other hand, Holter ECG recordings showed long nocturnal sinus pauses. As he was absolutely asymptomatic and free from any structural heart disease, he underwent a follow-up with repeated Holter monitorings for one year. During this period he decided on his own to stop practising sports; in spite of this sharp reduction in his overall physical activity, consecutive Holter monitorings showed that the sinus pauses were progressively increasing in duration (up to 9.2 seconds). With the hypothesis of a malignant vagotonia, he underwent a tilt test; however, we could not elicit any pauses or symptoms. The pauses grew longer over time; a endocavitary electrophysiologic test was performed, which showed no evidence of disease. To rule out the hypothesis of a sleep apnoea syndrome, he also underwent a polysomnography, including EEG, eye movement electromyography, arterial blood oxygen saturation and thoracic impedance: no alterations were detected with the exception of the sinus pauses, which appeared to be strictly linked to REM sleep, as suggested by the concurrent increase in rapid eye movements and desynchronized EEG. We hence made a diagnosis of sinus arrest during REM sleep (SAdRS), a very uncommon disease belonging to the parasomnias. Pauses were then quantified for one month by implanting a ECG loop recorder. As the patient became more and more upset and worried, and the pauses increased to nearly 12 seconds, we decided to implant a pacemaker, which is the only therapeutic option established in the literature for patients with SAdRS.

Food-dependent exercise-induced anaphylaxis: clinical and laboratory findings in 54 subjects

BACKGROUND

In some subjects, specific foods trigger anaphylaxis when exercise follows ingestion (specific food-dependent exercise-induced anaphylaxis, FDEIAn). Skin test and/or RAST positivity to foods suggest an IgE-mediated pathogenic mechanism. Others suffer from anaphylaxis after all meals followed by exercise, regardless of the food eaten (nonspecific FDEIAn). We sought to identify the culprit foods with a diagnostic protocol.

METHODS

We collected detailed histories and performed skin prick tests (SPT) with 26 commercial food allergens, prick plus prick tests (P+P) with 15 fresh foods (including 9 assessed with SPT), and RAST for 31 food allergens. Treadmill stress tests were administered after a meal without any positive food (food plus exercise challenge, FEC).

RESULTS

Among the 54 patients, 6 could not recall any suspect food. The other 48 suspected a specific food in at least one episode. The most frequent were tomatoes, cereals and peanuts. Fifty-two subjects were positive to at least one food (22 to more than 20), whereas 2 showed no positive results. All suspect foods were positive. SPT, P+P and RAST displayed different degrees of sensitivity. Each test disclosed some positivities not discovered by others. Two subjects reacted to FEC. Overall, 48 patients probably had specific FDEIAn and the other 6 nonspecific FDEIAn.

CONCLUSION

It is useful to test both in vivo and in vitro an extensive panel of foods. Avoidance of foods associated with skin test and/or RAST positivity for at least 4 h before exercise has prevented further episodes in all our patients with specific FDEIAn.

Does early repolarization in the athlete have analogies with the Brugada syndrome?

AIMS

To re-examine the prevalence and presentation of early repolarization in athletes and to compare it with electrocardiographic abnormalities observed in patients with the Brugada syndrome.

METHODS

Electrocardiograms of 155 male athletes and 50 sedentary controls were studied. Early repolarization was considered present if at least two adjacent precordial leads showed elevation of the ST segment > or =1 mm. Amplitude and morphology of ST elevation, the leads where it was present and the lead in which it showed its maximum value were analysed together with QRS duration, the presence of right ventricular activation delay, QT and QTc duration. Data were compared with those obtained by electrocardiograms of 23 patients with the Brugada syndrome.

RESULTS

Early repolarization was found in 139 athletes (89%) and 18 controls (36%, P< or =0.025), being limited to right precordial leads in 42 (30%) athletes and 13 (72%) controls (P< or =0.001). Only 12 (8.6%) athletes and one control (5.5%) with early repolarization had an ST elevation 'convex toward the top' in right precordial leads, similar to that seen in the Brugada syndrome. In athletes the maximum ST elevation was greater (2.3+/-0.6 mm) than in the controls (1.2+/-0.8 mm; P< or =0.004) but significantly lower than in patients with the Brugada syndrome (4.4+/-0.7 mm; P< or =0.0001). Patients with the Brugada syndrome also had a greater QRS duration (0.11+/-0.02 s) than athletes (0.090+/-0.011 s; P< or =0.0001) with early repolarization.

CONCLUSIONS

Early repolarization is almost always the rule in athletes but it is also frequent in sedentary males. Tracings somewhat simulating the Brugada syndrome were observed in only 8% of athletes without a history of syncope or familial sudden death. Significant differences exist between athletes with early repolarization and patients with the Brugada syndrome as regards the amplitude of ST elevation and QRS duration.

In vivo detection of coronary artery anomalies in asymptomatic athletes by echocardiographic screening

BACKGROUND

Anomalous origin of coronary arteries (AOCA) is a rare congenital disease. Although it may have a benign course, it has been identified as a frequent cause of sports-related sudden death. Unfortunately, in vivo detection of AOCA is not easy, as individuals with this anomaly often are asymptomatic and show no signs of myocardial ischemia. Presently, transthoracic two-dimensional echocardiography (TTE) is the only noninvasive, widely available tool to visualize the ostia and first tracts of coronary arteries.

OBJECTIVE

To assess the efficacy of TTE in the screening of AOCA in a large athletic population.

STUDY DESIGN

In a prospective study, we assessed the ostia and first tracts of coronary arteries in 3,650 subjects (mean age, 30+/-12 years) practicing different sports at various competitive levels. Subjects underwent a TTE examination in our laboratory for scientific or diagnostic purposes.

RESULTS

Technically satisfactory echocardiograms were obtained in 3,504 subjects (96%); a clear visualization of the ostia and first tracts of both coronary arteries was obtained in 3,150 cases (90%). Three asymptomatic athletes (0.09%) were suspected to have an AOCA; two with a right coronary artery origin from the left sinus, and one with a left coronary artery origin from the right sinus. Diagnosis was confirmed by coronary angiography.

CONCLUSIONS

Our study indicated that AOCA is rare in asymptomatic athletes. Systematic and accurate exploration of coronary anatomy in athletes referred for a diagnostic TTE examination may be useful in identifying those with AOCA.

Eosinophil-derived proteins in postprandial (food-dependent) exercise-induced anaphylaxis

BACKGROUND

Postprandial exercise-induced anaphylaxis (PPEIAn) is a form of EIAn in which the ingestion of food before the exercise is associated with the onset of symptoms. Skin reactivity and the presence of specific serum IgE to several food allergens suggest the occurrence of food-dependent allergic mechanisms.

METHODS

In order to study the involvement of eosinophils in the pathogenesis of PPEIAn we measured the changes in serum eosinophil cationic protein (ECP) and eosinophil protein X/eosinophil-derived neurotoxin (EPX/EDN) levels in 6 patients with PPEIAn, subjected to three separate challenges with either suspected foods only, exercise after a meal without or with suspected food ingestion.

RESULTS

We found serum levels of both eosinophil-derived proteins increased only in challenges including both exercise and suspected food ingestion. Symptoms of anaphylaxis occurred in 3 of these patients.

CONCLUSIONS

The increased release of eosinophil basic proteins in PPEIAn patients, caused by physical exercise following ingestion of suspected foods, is not obligatory for the definition of the syndrome.

Brief report: healed myocarditis as a cause of ventricular repolarization abnormalities in athlete's heart

In the past myocarditis has been suggested as a possible cause of repolarization abnormalities in sportsmen, but, to our knowledge, no direct in-vivo demonstration of this relationship has so far been found. We report the cases of three professional athletes with repolarization changes at rest and/or during exercise and mild segmental wall motion anomalies in the left ventricle on echocardiography, in whom myocarditis was diagnosed by non-invasive and invasive clinical investigations, including endomyocardial biopsy. We think that probably the frequency with which myocarditis is responsible for electrocardiographic and echocardiographic abnormalities in athletes has so far been underestimated, and that caution must be employed when interpreting minor segmental wall motion abnormalities on resting and exercise echocardiograms in trained subjects as being due to athlete's hart, especially when they present with repolarization changes.

Biopsy evidence of atrial myocarditis in an athlete developing transient sinoatrial disease

Atrial myocarditis causing transient sinoatrial disease (incessant atrial tachycardia alternating with sinoatrial pauses of up to 6 s in duration) in an athlete is reported. Diagnosis was undertaken by endomyocardial biopsy; biventricular and right atrial specimens were obtained. After a 6-month rest period, the atrial arrhythmias disappeared, and the athlete was able to resume his professional sporting activities.

Diagnostic work-up for food-dependent, exercise-induced anaphylaxis

Fourteen patients with suspected food-dependent, exercise-induced anaphylaxis (EIAn) were subjected to prick tests with commercial food extracts and common airborne allergens, prick + prick tests with fresh foods, determination of total IgE levels, and specific IgE for 31 foods (CAP System FEIA RAST). All were positive for two or more foods; 10 presented hypersensitivity to 11 or more foods. On the basis of these findings, history data, and responses to food-exercise challenges (treadmill stress tests 90 min after meals containing none of the suspected foods and none associated with skin-test and/or RAST positivity) and suspected food-exercise challenges (SFECs - administered after meals containing the suspected food), three patients were diagnosed as having specific food-dependent EIAn (for wheat in two cases, tomato in one). In nine others, the presence of specific IgE for numerous foods (including those suspected on the basis of histories and utilized in the SFECs) suggests involvement of specific food hypersensitivity, although SFEC confirmation could not be obtained. Avoidance of all foods associated with test positivity 4 h before exercise has prevented all further EIAn episodes in these 12 patients. In two others, the reactions did not appear to be related to IgE directed against specific food allergens, and these subjects have eliminated further reactions by avoiding all meals for the 4 h preceding exercise. These findings emphasize the importance of allergologic testing with a wide panel of food allergens (including foods used for seasoning, such as garlic or parsley) in all patients with suspected food-dependent EIAn. Prick + prick tests with fresh foods and the CAP System RAST disclosed numerous hypersensitivities.

Echocardiographic size of conductance vessels in athletes and sedentary people

The purpose of the present study was to assess the size of great and medium caliber arterial and venous vessels (conductance vessels) in athletes of different sports and sedentary people. Vessel size was measured by two-dimensional echocardiography in 15 professional cyclists, 15 highly-trained long-distance runners, 15 professional volley-ball players, 10 wheelchair basketball players, 11 wheelchair distance runners and 20 sedentary controls. The following vessels were imaged and measured: aortic arch, left carotid and left subclavian artery, right pulmonary artery, abdominal aorta and mesenteric artery, superior and inferior vena cava. Vessel size was considered in absolute value and normalized for body surface area (BSA). Among the able-bodied athletes, both cyclists and long-distance runners showed a generalized increase in vessels size in respect to controls, either absolute or normalized for BSA. The increase was highly significant for normalized inferior vena cava: cyclists, mean 15.1 mm, 95% confidence intervals 14.2 to 15.8 mm; long-distance runners, 15.8 mm, 15.3 to 16.4; controls, 10.5 mm, 9.8 to 11.3. Volleyball players also showed larger vessels than controls, but this feature was clearly related to their greater body size because statistical differences were attenuated or abolished by normalization for BSA. Wheelchair athletes exhibited significantly larger upper-body vessels but significantly smaller lower-body vessels than controls when normalized for BSA. In addition, wheelchair distance runners, who trained more intensively, had larger abdominal aorta and inferior vena cava than wheelchair basket players. Long-term endurance training leads to a generalized increase in arterial and venous conductance vessels size.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of myocarditis in athletes with minor arrhythmias and/or echocardiographic abnormalities

We report the clinical and instrumental data, including the endomyocardial biopsy findings, of six young athletes presenting with minor arrhythmias and/or echocardiographic abnormalities. In one of them, a left ventricular dilation with moderate depression of the systolic function had been attributed to an athlete's heart. A diagnosis of arrhythmogenic right ventricular dysplasia had been made in three others, one with right ventricular dilation and apical hypokinesia, and two with ventricular arrhythmias with QRS morphology of left bundle branch block. A myocarditis could be unequivocally established in four athletes (two with and two without fibrosis). In the remaining two, with a clinical history strongly suggesting a previously acute myocarditis, the endomyocardial biopsy specimen revealed a nonspecific fibrosis compatible but not definitely pathognomonic of a healed myocarditis. Our report suggests that a myocarditis may be a cause of minor rhythm disturbances and/or echocardiographic abnormalities in athletes. A prevalent localization of the inflammatory process in the right ventricle with or without the occurrence of ventricular arrhythmias with left bundle branch block morphology can mimic an arrhythmogenic right ventricular dysplasia. An early diagnosis of myocarditis in athletes is useful to avoid the risk of fatal arrhythmias, also considering that rest still keeps on being one of the most effective strategies in myocarditis management.

Food-dependent exercise-induced anaphylaxis: report of two cases

Exercise-induced anaphylaxis (EIAn) is a rare condition characterized by giant urticaria, angioedema and acute gastrointestinal symptoms that develops on exertion. In the most severe forms it may be associated with acute cardiorespiratory symptoms (laringeal stridor, wheezing), profound hypotension or syncope. In some individuals, EIAn characteristically occurs after a meal suggesting that the anaphylactic reaction is provoked by both exercise and ingestion of a foodstuff to which the patient has become sensitized. Two representative cases of severe food-dependent EIAn are described, which emphasize the need of performing a careful allergological evaluation in sportsmen with unexplained cardiovascular and/or respiratory symptoms during effort, especially when associated with other allergic manifestations and/or occurring in the post-prandial period.

Lactate and glucose electrochemical biosensors for the evaluation of the aerobic and anaerobic threshold in runners

Lactate and glucose are measured in whole blood of athletes running on a treadmill by using two extracorporeal electrochemical biosensors. The lactate sensor was fixed to an endocrine artificial pancreas (Betalike) which had been used in previous extracorporeal experiments. The lactate sensor gave a signal which resulted in a well defined curve that allowed the evaluation of the aerobic as well as the anaerobic threshold. The results obtained with the glucose sensor supported the theory that muscle anaerobic glycolysis is dependent on muscle glycogen rather than on blood glucose.

Coronary arteries and athlete's heart

An increase of coronary artery size after endurance training has been suggested by experimental data on animals and anecdotal autopsy reports in men. However, systematic studies on in vivo coronary anatomy of athletes have been lacking so far. We utilized two-dimensional echocardiography (2DE) to explore non-invasively the coronary anatomy of endurance athletes. Twenty long-distance runners (LDR) and 20 matched sedentary controls (SC) were studied initially. Visualization of the ostia and main trunks of-right (RCA) and left coronary artery (LCA) was obtained in 90-100 p. 100 of LDR and 70-75 p, 100 of SC. Collateral branches of LCA (anterior descending artery and circumflex branch) and RCA were visualized respectively in 60-70 p. 100 and 30-40 p, 100 of cases. The very good quality of images made possible the measurement of LCA and RCA size. LDR as a group had significantly larger coronary arteries than SC: this was associated with significant left and right ventricular enlargement and hypertrophy. These results have been further confirmed in a large survey of triathletes, swimmers, water-polo players, young LDR and prepubescent football players. Increase of coronary artery size is a well-documented effect of endurance training which can be easily investigated with 2DE, However, the large interindividual variability and the observation of very large coronary arteries in adolescent subjects suggest that genetic factors may also play a role in determining the final size of the coronary vessels.

[Echocardiographic visualization of the coronary arteries in endurance athletes]

Visualization of left (LCA) and right coronary artery (RCA) by two-dimensional echocardiography (2-DE) was tried in 20 highly-trained endurance athletes and 20 normal sedentary controls using multiple echo planes. On the standard parasternal short axis aortic root view, the ostium of LCA was successfully visualized in all 20 athletes (100 percent) and in 18 controls (90 percent), the left main trunk in 19 athletes (95 percent) and 14 controls (70 percent) and a distinct bifurcation of the main trunk in 4 athletes (20 percent) and 2 controls (10 percent). In another 2 athletes, the initial tract of the left anterior descending artery and of the left circumflex branch could also be identified. With the same echo view, both from left or right sternal border, the ostium of RCA was visualized in 19 athletes (95 percent) and 16 controls (80 percent), the right main trunk in 18 athletes (90 percent) and 15 controls (75 percent) and a distinct bifurcation of RCA with one branch in 9 athletes (45 percent) and none of controls (p less than 0.025). Moreover, visualization of the distal tract of RCA was obtained on the parasternal long axis view of right ventricle in 15 athletes (75 percent) and 6 controls (30 percent, p less than 0.025). The very good quality of the 2-DE images allowed to measure the size of the ostia and initial tracts of both coronary arteries and the length for which the vessels could distinctly be followed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac and metabolic investigations during 24 hour endurance skiing (Pinzolo, Italy)]

In the "24-hour Cross Country Ski Race of Pinzolo" skiers attempt to cover as long as possible distances within 24 hours. Cardiac and metabolic changes of 6 volunteer cross country skiers, aging 29 to 39 years, participating to the individual competition, were analysed. All skiers had negative clinical examination and resting standard 12-lead ECG, except for one who had a midsystolic click on auscultation suggesting the presence of mitral valve prolapse. They were submitted to 48-hour Holter monitoring (HM) going from 3:00 p.m. of the day before the race up to one hour after the end of competition. The period of HM going from 3 p.m. of the day before to 1.00 p.m. of the day of race (one hour before the start) was utilized as control as concerns arrhythmias, ST-T wave and QT interval changes observed during the period of competition. In all 6 skiers, standard 12-lead ECG was again recorded on completion of race. The following serum indexes were obtained in basal conditions and within one hour after the end of race: electrolytes (Na+, K+), Myoglobina (MG) and the enzymes GOT, GPT, LDH, CK and CK-MB. Complete urine analysis was also obtained before and immediately after the race. The distance covered by the skiers ranged from 189 to 260 Km, except for the skier with systolic click who covered 95.7 Km within 12 hour and then retired from the race for acute pain of knee.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of ankylosing spondylitis with hairy cell leukemia: a previously once reported case

We report a case of ankylosing spondylitis associated with hairy cell leukemia. This is the second observed case (I3) of ankylosing spondylitis with a B-type lymphoproliferative disorder which allows us to make some observations about the pathogenesis of these rare diseases.

[Somatostatin and the cardiovascular system: experiences and prospective use]

The recent demonstration that intravenous administration of somatostatin, an ubiquitous peptide-like substance, may interrupt paroxysmal supraventricular tachycardia in man has disclosed new perspectives in the assessment of the mechanisms of neuro-humoral cardiac regulation in normal and pathologic conditions. Prospective studies on normal subjects and diabetics with and without autonomic cardiac neuropathy, helped in giving an outlook on the mechanism by which somatostatin acts on the human heart. This substance exerts in vivo a powerful chronotropic and dromotropic influence on sinoatrial and A-V node cells both in normals and diabetics with and without autonomic cardiac neuropathy. This influence is blocked by preventive administration of atropine or atropine plus metoprolol (intrinsic heart rate). Since somatostatin-like-substances have been found in cholinergic postganglionic neurons of the cardiac vagus of some animals, the demonstrated "vagomimetic" action of somatostatin on human cardiac cells seems to support the hypothesis that also the human heart may contain vagal somatostatinergic neurons with modulatory function on the heart rate and rhythm. Present observations disclose new perspectives in the pathophysiology and therapy of cardiac arrhythmias.