Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology

Preparticipation screening of young competitive athletes for cardiovascular disorders

The beneficial effects of regular physical exercise on cardiovascular morbidity and mortality are well documented. In rare cases, however, athletes with cardiovascular abnormalities are at increased risk of exercise-related sudden cardiac death (SCD). Paradoxically, most SCDs can be attributed to cardiovascular abnormalities that can be identified during an athlete's life. Such abnormalities can be minimized by several therapeutic strategies, including insertion of an implantable cardioverter-defibrillator. Based on these considerations, the medical and sporting governing bodies recommend preparticipation cardiovascular screening (PPS) in young competitive athletes (aged <or= 35 years) to identify potentially fatal cardiovascular disorders. However, PPS is associated with several controversies related to the efficacy, cost-effectiveness, and impact of false-positive results. This article aims to provide a detailed overview of the issues concerning PPS based on current evidence.

Anomalous right coronary artery origin in a high school athlete

Coronary anomalies are the cause of 12% of sudden deaths among athletes. Similarly anomalous coronary origin from the opposite sinus is often found at autopsy. The use of echocardiography to screen for these types of defects may provide a potentially life-saving diagnosis. The authors present a case that highlights the utility of echocardiography as part of a comprehensive screening program for athletes.

Recommendations for Clinical Assessment, Sports Participation, and Management in Hypertensive Athletes

Athleticism is often associated with optimal health; however, some athletes have high blood pressure (BP) despite being physically active. Using proper guidelines to determine a BP diagnosis is essential when working with both children and adults who are physically active because basal BP levels rise during physical activity. Once a physician has determined an athlete is hypertensive, a full clinical assessment may be required to identify possible etiologies for the condition and furthermore to establish appropriate BP management. Special recommendations for sport participation can follow. Sport participation is dependent on, but is not limited to, coexisting cardiovascular risk factors and associated clinical conditions, BP condition, and evidence of end-organ damage. This article reviews the available research literature on the diagnosis of hypertension, recommendations for clinical assessments, and special considerations of BP management and sport participation to ensure the safety of hypertensive patients/athletes.

Recommendations for interpretation of 12-lead electrocardiogram in the athlete

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

Sudden death in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is regarded as the most common cause of sudden cardiac death in young people (including trained athletes). However, assessing sudden death (SD) risk and identifying the most appropriate candidates for prophylactic device therapy is a complex process compounded by the unpredictability of the underlying arrhythmogenic substrate, absence of a single dominant and quantitative risk maker for this heterogeneous disease, and also the difficulty encountered in assembling sufficiently powered prospective and randomized trials in large patient populations. Patients with multiple risk factors and most young patients with one strong and unequivocal risk marker can be considered candidates for primary prevention defibrillators. Despite certain limitations, the current risk factor algorithm (when combined with a measure of individual physician judgment) has proved to be an effective strategy for targeting high-risk status. This approach has served the HCM patient population well, as evidenced by the significant appropriate defibrillator intervention rates, although a very small proportion of patients without conventional risk factors may also be at risk for SD. Indeed, the introduction of implantable defibrillators to the HCM patient population represents a new paradigm for clinical practice, offering the only proven protection against SD by virtue of effectively terminating ventricular tachycardia/fibrillation. In the process, implantable defibrillators have altered the natural history of HCM, potentially providing the opportunity of normal or near-normal longevity for many patients. Prevention of SD is now an integral, albeit challenging, component of HCM management.

Subclinical hyperthyroidism and sport eligibility: an exploratory study on cardiovascular pre-participation screening in subjects treated with levothyroxine for multinodular goiter

BACKGROUND

Subclinical hyperthyroidism (sHT) affects cardiovascular (CV) morphology and function; whether such changes can impact on sport eligibility is unclear.

AIM

This exploratory study evaluated the CV system and sport eligibility in athletes with levothyroxine-induced sHT, in the setting of mandatory pre-participation screening.

SUBJECTS AND METHODS

A full, non-invasive CV screening (history and physical examination, 12-lead ECG, echocardiography, 24-hour Holter ECG, exercise stress test) was performed in two groups of untrained female athletes affected by non-toxic multinodular goiter. One group was taking levothyroxine at mildly suppressive doses (TG) whereas the other was untreated (UG). There was also a group of healthy controls (HC).

RESULTS

In TG the following characteristics were observed: a) a higher resting heart rate (HR; p<0.01 and p<0.05, vs HC and UG respectively), b) a thicker left ventricular posterior wall (p<0.05 vs HC, and p<0.05 vs HC and UG, respectively), c) a higher mean HR during the 24-hour Holter ECG (p<0.01 and p<0.05, vs HC and UG respectively), and d) a lower achieved maximum work load (p<0.05, vs HC). No differences in the prevalence of cardiac arrhythmias among groups were observed. Sport eligibility was granted to all except one subject in the TG.

CONCLUSIONS

Although some alterations were found in athletes with levothyroxine-induced mild sHT, these are probably of limited clinical relevance and they did not contraindicate sport participation in the majority of cases. Future research to address both health risks and the need for specific evaluations (e.g. free thyroxine, TSH, echocardiography) during the preparticipation screening of athletes with sHT is warranted.

Electrocardiographic abnormalities in young athletes with mitral valve prolapse

BACKGROUND

Mitral valve prolapse (MVP) is the most common primary valvular abnormality in a young population. In some individuals, MVP is silent or associated with palpitations, dizziness, chest pain, and abnormal electrocardiogram (ECG) repolarization with or without ventricular arrhythmias.

HYPOTHESIS

The aim of the present study was to assess the occurrence of the clinical and electrocardiographic abnormalities in young athletes with silent MVP.

METHODS

A group of 10 children, who have been sport training intensively, with preparticipation silent MVP were examined for symptoms and/or ECG abnormalities. The diagnosis of MVP was made by echocardiography.

RESULTS

Three athletes were asymptomatic at initial presentation. The other 7 athletes presented with symptoms. The QTc intervals > 440 msec were recorded in 2 athletes (1 with syncope). Abnormal ECG repolarization was found in 7 athletes (4 athletes were symptomatic and 3 were asymptomatic). A large variety of T-waves was registered in athletes who presented with symptoms. In asymptomatic athletes, the tall and flat T-waves were recorded.

CONCLUSIONS

Young athletes with MVP are often predisposed to electrocardiographic abnormalities of ventricular repolarization, which requires annual cardiologic evaluation.

Cardiovascular issues in boxing and contact sports

Despite the inherent risks associated with exercise in general and boxing in particular, the sport has had a limited number of catastrophic cardiovascular events. Screening should be based on risks involved and become more extensive with the advancement of the athlete. Anatomic and electrophysiologic risks need to be assessed and may preclude participation with resultant life style and economic complications. There should be adequate preparation for the rare potential cardiovascular complication at all events, with the ability to rapidly assess and treat arrhythmias.

[Myocarditis and sudden cardiac death in athletes. Diagnosis, treatment, and prevention]

Myocarditis is the reason for sudden cardiac death in 5-22% of athletes < 35 years of age. Actually, parvovirus B19 and human herpes virus 6 are the most important pathogens. Clinical presentation of myocarditis is heterogeneous, with all courses between asymptomatic and fulminant reported. Especially in athletes it is important to take subtle discomforts seriously and initiate further evaluation. Electrocardiogram, laboratory parameters, serologic markers, and echocardiography are helpful in diagnosis of myocarditis, but are not specific. Magnetic resonance imaging (MRI) of the heart has become an important tool in the evaluation of patients with myocarditis and allows noninvasive appraisal of myocardial inflammation using late enhancement. However, MRI is not able to assess viral persistence. Therefore, endomyocardial biopsy (EMB) remains the gold standard in diagnosis of myocarditis. When considering EMB in these athletes one should not ignore spontaneous healing in 50% of patients with myocarditis. Contrariwise, specific therapy (e.g., immunosuppression, interferon, immunoglobulins) for myocarditis is only feasible after getting results of EMB. When myocarditis is verified, athletes have to withdraw from sport for at least 6 months. Before restarting physical activity, a detailed examination is necessary and most of the patients will undergo another EMB. For prevention of myocarditis and sudden cardiac death it is recommended to stop elite sport for 4 weeks after an unspecific infection. Whether moderate sport can be started earlier is unclear.

The risk of cardiac events and genotype-based management of LQTS patients

This review discusses the risk of cardiac events and genotype-based management of LQTS. We describe here the genetic background of long QT syndrome and the eleven different genes for ion-channels and a structural anchoring protein associated with that disorder. Clinical Background section discusses the risk of cardiac events associated with different LQTS types. Management and Prevention section describes in turn gene-specific therapy, which was based on the identification of the gene defect and the dysfunction of the associated transmembrane ion channel. In patients affected by LQTS, genetic analysis is useful for risk stratification and for making therapeutic decisions. A recent study reported a quite novel pathogenic mechanism for LQTS and suggested that treatments aimed at scaffolding proteins rather than specific ion channels may be an alternative to antiarrhythmic strategy in the future.

Return-to-play decisions in athletes with cardiac conditions

Many sets of guidelines written by experts in their fields can assist sports medicine physicians to make return-to-play decisions for athletes with known or suspected cardiac conditions. These guidelines can be divided into pre-participation screening guidelines, such as the 2007 American Heart Association (AHA) 12-element screening examination, and specific recommendations for those with heart disease or symptoms. Several important documents fall into the latter category. Among these are the 36th Bethesda Guidelines, the European Society of Cardiology Guidelines, the AHA Consensus Document for Young People with Genetic Conditions, the Heart Rhythm Society Guidelines, and the Guidelines for Masters Athletes. Guidelines are designed to enhance the sports medicine physician's probability of detecting heart disease and making wise participation and return-to-play decisions in athletes with high-risk cardiac conditions, such as hypertrophic cardiomyopathy, anomalous coronary artery, myocarditis, and valvular heart disease. Guidelines also aid in writing exercise prescriptions for those deemed too high risk for sports participation. Because the guidelines may not be entirely consistent on all topics, or based on opinion rather than research evidence, many cases require additional input from a cardiologist or electrophysiologist. Guidelines address not only specific disease entities, but also how corrective surgery, ablations, implantable defibrillators, or drug therapy can influence return-to-play decisions. They are updated as new studies become available to provide physicians with the most up-to-date information.

Dominance in cardiac parasympathetic activity during real recreational SCUBA diving

It was already established that exposure to hyperbaric conditions induces vagal-depended bradycardia but field study on autonomic nervous system (ANS) activity during self-contained underwater breathing apparatus (SCUBA) diving is lacking. The aim of the present study was to evaluate ANS modifications during real recreational SCUBA diving using heart rate variability analysis (timedomain, frequency-domain and Poincaré plot) in 10 experienced and volunteers recreational divers. Mean RR, root mean square of successive differences of interval (rMSSD), high frequency of spectral analysis and standard deviation 1 of Poincaré Plot increased (P < 0.05) during dive. Low frequency/high frequency ratio decreased during dive (P < 0.05) but increased after (P < 0.05). Recreational SCUBA diving induced a rise in vagal activity and a decrease in cardiac sympathetic activity. Conversely, sympathetic activity increases (P < 0.05) during the recovery.

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

BACKGROUND

Sudden deaths in young competitive athletes are highly visible events with substantial impact on the physician and lay communities. However, the magnitude of this public health issue has become a source of controversy.

METHODS AND RESULTS

To estimate the absolute number of sudden deaths in US competitive athletes, we have assembled a large registry over a 27-year period using systematic identification and tracking strategies. A total of 1866 athletes who died suddenly (or survived cardiac arrest), 19+/-6 years of age, were identified throughout the United States from 1980 to 2006 in 38 diverse sports. Reports were less common during 1980 to 1993 (576 [31%]) than during 1994 to 2006 (1290 [69%], P<0.001) and increased at a rate of 6% per year. Sudden deaths were predominantly due to cardiovascular disease (1049 [56%]), but causes also included blunt trauma that caused structural damage (416 [22%]), commotio cordis (65 [3%]), and heat stroke (46 [2%]). Among the 1049 cardiovascular deaths, the highest number of events in a single year was 76 (2005 and 2006), with an average of 66 deaths per year (range 50 to 76) over the last 6 years; 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, whereas only 11% occurred in females (although this increased with time; P=0.023). The most common cardiovascular causes were hypertrophic cardiomyopathy (36%) and congenital coronary artery anomalies (17%).

CONCLUSIONS

In this national registry, the absolute number of cardiovascular sudden deaths in young US athletes was somewhat higher than previous estimates but relatively low nevertheless, with a rate of <100 per year. These data are relevant to the current debate surrounding preparticipation screening programs with ECGs and also suggest the need for systematic and mandatory reporting of athlete sudden deaths to a national registry.

Anabolics and cardiomyopathy in a bodybuilder: case report and literature review

BACKGROUND

Athletes use androgenic-anabolic steroids to increase strength and muscle mass. Several case reports suggest that it may lead to dilated cardiomyopathy.

METHODS AND RESULTS

We report a case of a 41-year-old bodybuilder with severe systolic dysfunction and Class IV heart failure despite maximal medical therapy. He used anabolic steroids and insulin growth factor, and did not have any other risk factors for cardiomyopathy. We briefly review the literature and summarize other reported cases with similar scenarios. In most of them cardiomyopathy was at least partially reversible after discontinuation of anabolics.

CONCLUSIONS

Abuse of anabolic steroids may be an uncommon cause of cardiomyopathy in young and otherwise healthy individuals.

Speckle tracking for left ventricle performance in young athletes with bicuspid aortic valve and mild aortic regurgitation

AIMS

Longitudinal peak systolic strain (LPSS) quantifies regional and global heart function. Few data are available on left ventricle (LV) performance in young athletes with bicuspid aortic valve (BAV), where a pattern of mild aortic insufficiency is relatively frequent, and the ejection fraction (EF) is often normal for a long time. We report the measurement of LV strain in young BAV athletes.

METHODS AND RESULTS

Three groups (20 athletes with BAV, 20 healthy athletes, and 20 sedentary healthy subjects, all aged 25 +/- 3 years) underwent standard echo examination to evaluate LPSS at the basal and medium-apical segments of the lateral wall (LW) and interventricular septum (IVS) of the LV. LPSS was within the normal range; however, in BAV athletes, the LPSS of the basal segments tended to be lower (S%IVS(basal), -17.7 +/- 2.7; S%LW(basal), -14.2 +/- 2.2; S%IVS(med-apic), -21 +/- 3.5; S%LW(med-apic), -18.8 +/- 4.2), producing a gradient from basal to apical regions. The EF was normal in all subjects.

CONCLUSION

Young trained BAV athletes have normal LV performance. Nevertheless, these athletes tend to have lower strain than healthy subjects in the LV basal segments. The clinical implications of this finding are uncertain and require further investigation.

[Sudden cardiac death in athletes]

The entity of sudden cardiac death in young athletes has been known since the year 490 B.C. when young Greek soldier Phidipides had run the distance from Marathon to Athens and suddenly fell down dead. In the last twenty years, sudden death of famous athletes have attracted huge attention of medical and social community; afterwards both American and European Cardiology Societies started to publish periodically guidelines for preparticipation screening. These guidelines have focused on both identifying athletes with potential cardiovascular risk for sudden death and eligibility conditions for athletes participating in competitive sports. Structural and functional abnormalities causing sudden cardiac death in young athletes have been identified by autopsy-based studies. Unrecognized congenital cardiovascular abnormalities associated with excessive physical effort create background for electrophysiological instability and occurrence of malignant ventricular tachyarrhythmia and consequent death. The most frequent causes of sudden cardiac death in young athletes include hypertrophic cardiomyopathy, anomalies of the coronary arteries and idiopathic left ventricular hypertrophy. Current ACC/AHA & ESC guidelines should be widely used in order to reduce potential sudden cardiac death in young athletes.

Contemporary approaches to the identification of athletes at risk for sudden cardiac death

PURPOSE OF REVIEW

The appropriate screening strategy to prevent sudden cardiac death (SCD) in athletes remains a challenging and a highly debated issue. The purpose of this review is to examine the added value and controversies of including a 12-lead electrocardiogram (ECG) in addition to a comprehensive personal and family history during preparticipation screening of cardiovascular abnormalities in athletes.

RECENT FINDINGS

Studies in support of ECG screening are evolving rapidly, utilizing more rigorous ECG criteria with a lower total positive rate- and thus reduced levels of false positives. Reported estimates on the incidence of SCD in young athletes vary widely based on the methods of data collection and have likely underrepresented the incidence of SCD with implications on screening recommendations. More accurate calculations of SCD incidence combined with lower total positive rates yield a promising cost-effectiveness analysis in favor of universal ECG screening of athletes.

SUMMARY

The devastating impact of SCD in young athletes warrants the commitment of additional resources to identify those at risk. It is time for a systematic preparticipation screening program for all competitive athletes, using at least a standardized comprehensive personal and family history questionnaire and a screening ECG at the time of matriculation to high school and college. Although additional outcomes-based research is required, improved efforts to expand the infrastructure necessary for effective cardiac screening in young athletes are recommended.

[Sportman's myocardial infarction]

Sport related myocardial infarctions are rare. They concern a population mainly male, of more than 35 years, with a high prevalence of smoker. The initial clinical presentation is serious, with frequent ventricular fibrillations, the mode of revelation that can be a sudden death. The angiographic data mainly shows a single vessel disease or no significant lesion. These characteristics put down the problem of the validity of preparticipation screening for cardiovascular abnormalities, and in particular the place of exercise stress testing. It is advisable to continue the reflexion to determine a reasonable strategy in the tracking of the subjects at risk. This tracking, the correction of cardiovascular risk factors, the diffusion of elementary rules good sporting practices and the management of sudden death with rapid defibrillation on the sporting sites and complexes are current measurements essential to develop.

Relation of physical activity, cardiac function, exercise capacity, and quality of life in patients with a systemic right ventricle

Exercise is recommended in patients with left ventricular failure. Although right ventricular failure is common in patients with a systemic right ventricle (RV), no data are available on the effect of physical activity in these patients. The aim of this study was to evaluate the relation of physical activity and cardiac function, exercise capacity, and quality of life in patients with a systemic RV. Forty-seven patients (64% men, mean age 35 years, range 21 to 69) with a systemic RV (31 with an atrially switched transposition of the great arteries and 16 with a congenitally corrected transposition of the great arteries) were included. Cardiac function was assessed by cardiovascular magnetic resonance or computed tomography, exercise tests, and serum N-terminal prohormone brain natriuretic peptide (NT-pro-BNP) levels. Habitual physical activity was assessed using the Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) and quality of life using the Medical Outcomes Study Short Form 36-Item Health Survey. Mean systemic right ventricular ejection fraction was impaired (36.8 +/- 7.8%), as was maximal exercise capacity (78.5 +/- 23.9% of predicted). NT-pro-BNP level was increased (median 269 ng/L, range 34 to 4,476). Mean SQUASH score was 6,808 +/- 3,241, indicating a decreased level of habitual physical activity. Although patients' scores on mental quality-of-life domains were comparable to the general population, scores on most physical quality-of-life domains were significantly lower. SQUASH scores were found to be a significant predictor for exercise capacity (p <0.01) and physical quality of life (p <0.001). However, we found no relation between SQUASH scores and right ventricular ejection fraction or NT-pro-BNP. In conclusion, physical activity in patients with a systemic RV is positively associated with exercise capacity and quality of life, irrespective of cardiac performance.

Sudden cardiac death in pediatrics

PURPOSE OF REVIEW

Sudden cardiac death (SCD) is a rare but tragic event in children. This review highlights the important advances in this field during the last year, both in the understanding of the underlying diseases and in improvements in the management of patients at risk for SCD.

RECENT FINDINGS

The study of SCD has focused on several major themes: progress in understanding the causes and treatments of genetic cardiovascular diseases, improved management of patients with congenital heart disease with SCD risk, treatment strategies for SCD risk reduction in patients with cardiomyopathies, and defining guidelines for athletic preparticipation screening.

SUMMARY

With advances in understanding of the causes and risk factors for SCD, management of children at risk for SCD continues to improve. This includes improved clinical criteria for identifying SCD risk as well as optimizing management strategies such as exercise restriction, antiarrhythmic medications, and implantable cardioverter defibrillator therapy.

Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy

OBJECTIVES

The purpose of this study was to evaluate ethnic differences in left ventricular (LV) remodeling between highly-trained athletes of African/Afro-Caribbean (black) and Caucasian (white) athletes.

BACKGROUND

The upper limits of left ventricular hypertrophy (LVH) are established in white athletes and aid the differentiation of physiologic LVH from hypertrophic cardiomyopathy (HCM). However, there are few data regarding LV remodeling in black athletes, in whom deaths from HCM are more prevalent.

METHODS

Between 2003 and 2007, 300 nationally ranked black male athletes (mean age 20.5 years) underwent 12-lead electrocardiogram and 2-dimensional echocardiography. The results were compared with 150 black and white sedentary individuals and 300 highly-trained white male athletes matched for age, size, and sport.

RESULTS

Black athletes exhibited greater LV wall thickness and cavity size compared with sedentary black and white individuals. Black athletes had greater LV wall thickness compared with white athletes (11.3 +/- 1.6 mm vs. 10 +/- 1.5 mm; p < 0.001). In absolute terms, 54 black athletes (18%) had LV wall thickness >12 mm compared with 12 white athletes (4%), and 3% of black athletes exhibited LV wall thickness >/=15 mm compared with none of the white athletes. Black athletes with LVH displayed an enlarged LV cavity and normal diastolic function.

CONCLUSIONS

Black athletes develop a greater magnitude of LVH compared with white athletes; therefore, extrapolation of conclusions derived from white athletes has the potential of generating false-positive diagnoses of HCM in black athletes.

Competitive sport after coronary angioplasty: suggested eligibility criteria for moderate-high intensity sport

Physical activity is encouraged following coronary revascularization to reduce restenosis and progression of coronary disease. Some patients may even opt to take on or resume competitive sport. Therefore, sport physicians have to face a decision whether patients are eligible or not to do so. The most recent Italian cardiology protocols regarding eligibility for competitive sport suggest that after examination on a case-by-case basis, subjects with isolated stenosis of a coronary vessel may be deemed eligible even for sports involving high-cardiovascular demand. This is possible if the subject is at low risk, has successfully undergone coronary angioplasty at least 1 year earlier, and undergoes obligatory 6-monthly follow-up examinations. In our view, in addition to fulfilling the criteria drawn up by the cardiology protocols, patients should also have completed a period of cardiologic rehabilitation, should not display perfusion defects on exercise myocardial scintigraphy (carried out annually), and should be free from cardiovascular risk factors, for which we propose restrictive threshold values. If an individual has not completed an adequate period of rehabilitation or presents cardiovascular risk factors, a further assessment should be made after at least 8 weeks of cardiac rehabilitation and after the risk factors have been corrected.

Microvolt T-wave alternans for risk stratification in athletes with ventricular arrhythmias: correlation with programmed ventricular stimulation

BACKGROUND

Aim of our study is to evaluate the role of T-wave alternans (TWA) to stratify the risk of sudden cardiac death in athletes (Ath) with complex ventricular arrhythmias (VA), and to document a possible correlation between TWA and electrophysiological testing (EPS) results.

METHODS

We studied 85 Ath with VA (61 M, mean age 32 +/- 11 years). In all cases a cardiological evaluation was performed, including TWA and EPS. The patients were evaluated during a follow-up of 30 +/- 21 months. The end point was the occurrence of sudden death (SD) or malignant ventricular tachyarrhythmias (VT).

RESULTS

TWA was negative in 57 Ath (68%), positive in 15 (18%) and indeterminate in 13 (14%). All subjects with negative TWA did not show induction of VT at EPS, with significant correlation between negative TWA and negative EPS (P < 0.001). All Ath with positive TWA also had VT induced by a EPS, with significant correlation (P < 0.001). By contrast, our data did not show significant correlation between indeterminate TWA and positive or negative EPS. However, there was significant correlation between abnormal TWA test (positive + indeterminate) and inducibility of VT at EPS (P < 0.001). During follow-up we observed a significant difference in end point occurrence (VT or SD) between Ath with negative or abnormal TWA and between Ath with negative or positive EPS.

CONCLUSION

TWA confirm its role as a simple and noninvasive test, and it seems useful for prognostic stratification of Ath with VA.