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Garatachea N, Pueyo E, Eijsvogels TM. Prevention of Sudden Death in Sports: A Global and Multidisciplinary Observatory for Scientific Research and Knowledge Transfer (PREMUBID). Rev Cardiovasc Med 2023; 24:12. [PMID: 39076883 PMCID: PMC11270393 DOI: 10.31083/j.rcm2401012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/17/2022] [Accepted: 11/28/2022] [Indexed: 07/31/2024] Open
Abstract
Background The health benefits of sports and exercise training are well known. However, an acute bout of exercise transiently increases the risk of sudden cardiac death (SCD). To minimize the cardiovascular risks of exercise, more insight into the prevention and causes of SCD is needed. Methods The observatory for the prevention of sudden death in sports, PREMUBID, was created with the aim of fostering research to assess the benefits and risks of exercise at different volumes and intensities and to get insight into the underlying mechanisms of potentially cardiac (mal) adaptations. Results The observatory gathers researchers from a wide range of disciplines working at institutions in Europe and North America. The guiding principles of PREMUBID are to broaden the understanding of SCD in sports, strengthening collaborative research across the globe, and to develop, implement and evaluate robust pre-participation screening and emergency care strategies to further reduce the number of fatal cardiac events in sport events. During the inaugural meeting of the observatory, members and affiliated researchers discussed possibilities to initiate collaborative research projects and to exchange staff and students to share information and practices to prevent SCD. The final goal is to translate the obtained knowledge to understandable messages for the general population and healthcare workers to ensure that the population at large benefits from it. Conclusions The PREMUBID consortium aims to produce novel knowledge and insights in SCD prevention, in order to maximize the health benefits associated with acute and long-term exercise training.
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Affiliation(s)
- Nuria Garatachea
- Growth, Exercise, NUtrition and Development (GENUD) Research Group, University of Zaragoza, 50009 Zaragoza, Spain
- Department of Physiatry and Nursing, Faculty of Health and Sport Science (FCSD), University of Zaragoza, 22002 Huesca, Spain
- Instituto Agroalimentario de Aragón (IA2), Centro de Investigación y Tecnología Agroalimentaria de Aragón (CITA), Universidad de Zaragoza, 50013 Zaragoza, Spain
| | - Esther Pueyo
- Biomedical Signal Interpretation and Computational Simulation (BSICoS), Aragón Institute for Engineering Research (I3A), IIS Aragón, University of Zaragoza, 50018 Zaragoza, Spain
- CIBER de Bioingeniería, Biomateriales y Nanomedicina, CIBER-BBN, 28029 Madrid, Spain
| | - Thijs M.H. Eijsvogels
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands
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2
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Palermi S, Sirico F, Fernando F, Gregori G, Belviso I, Ricci F, D'Ascenzi F, Cavarretta E, De Luca M, Negro F, Montagnani S, Niebauer J, Biffi A. Limited diagnostic value of questionnaire-based pre-participation screening algorithms: a "risk-exposed" approach to sports activity. J Basic Clin Physiol Pharmacol 2022; 33:655-663. [PMID: 35647906 DOI: 10.1515/jbcpp-2022-0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/26/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Several pre-participation screening algorithms (PPSAs) have been proposed to assess sports eligibility in different populations. They are usually based on self-administered questionnaires, without further medical assessment if no risk factors are documented. The Med-Ex "Formula Benessere" worksite program includes a complete cardiovascular (CV) screening for all participants. The purpose of this study was to assess PPSAs accuracy in detecting medical and/or CV abnormalities in the general population, comparing the results with the date derived from Med-Ex program. METHODS The Med-Ex medical evaluation, consisting of medical history, physical examination (including body composition), resting electrocardiogram (ECG) and exercise stress test in 464 male subjects (38.4 aged) was analyzed and matched to several PPSAs - Physical Activity Readiness Questionnaire (PAR-Q) (2002-2020), American Heart Association (AHA)/American College of Sport Medicine (ACSM) (1998-2009-2014-2015), European Association of Cardiovascular Prevention and Rehabilitation (EACPR) (2011) - retrospectively simulated. RESULTS Five-hundred and 67 abnormalities were detected though Med-Ex medical evaluation, and one-fourth (24%) would have been undetected applying PPSA alone. In particular 28% of high blood pressure, 21% of impaired fasting glycaemia, 21% of high Body Mass Index (BMI) values and 19% of ECG abnormalities would have been missed, on average, by all PPSAs. CONCLUSIONS The simulation analysis model performed in this study allowed to highlight the limits of PPSAs in granting sport eligibility, compared to a medical-guided CV screening. These findings emphasize the importance of a more balanced approach to pre-participation screening that includes a thorough evaluation of the cost/benefit ratio.
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Affiliation(s)
- Stefano Palermi
- Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy.,Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Felice Sirico
- Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy.,Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Fredrick Fernando
- Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | - Giampietro Gregori
- Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
| | - Immacolata Belviso
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, "G. d'Annunzio" University, Chieti, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Elena Cavarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Mariarosaria De Luca
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Francesco Negro
- Cardiology Unit, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Stefania Montagnani
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Josef Niebauer
- University Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Alessandro Biffi
- Med-Ex, Medicine & Exercise srl, Medical Partner Scuderia Ferrari, Rome, Italy
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Abstract
Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.
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Affiliation(s)
- Asterios Deligiannis
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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4
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Dursun M, Bilir E, Kaymaz K, Sakarya S. Pre-Participation Screening of Athletes: Primary Health Care Physicians' Knowledge, Experience, and Approach in Turkey. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:41-53. [PMID: 33795981 PMCID: PMC7995949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Pre-participation screening (PPS) is crucial for assessing the competitive athletes since their risk of sudden death is higher than non-athletes. In Turkey, PPS is performed at the primary health care setting by primary care physicians (PCPs) who are family medicine specialists (FMSs) or general practitioners (GPs). Although there are national guidelines, there is no legal regulation for this process. This study aims to evaluate PCPs' knowledge, experience, and approach about PPS. We prepared an online survey for PCPs and used non-probabilistic sampling. PPS attitudes and practices were analyzed and compared according to factors such as experience, education, and being GP or FMS. Of the 214 PCPs included in the study, 39.3% were female. The mean age was 44.9 years (SD:8.88). The average work experience was 7.9 years. Most participants were aware of their authorization to perform PPS (89.7%) and had previously prepared it (90.2%). However, 6.5% of them felt confident in performing PPS. Only 13.1% were aware of the guidelines. Almost 25% of the participants stated being informed about the subject at some part of their career, but this did not affect the confidence or referral decisions. In addition to medical history and physical examination, further testing was considered necessary by 96.3% of the participants. Significantly more tests were ordered by GPs than FMSs (p=0.026 and p=0.011, respectively). The accurate referral decision ratio was 59.3%, without difference between FMSs and GPs (p=0.216). We found that awareness of the guidelines was low among PCPs who lack confidence in PPS. These factors collectively increased the tendency for unnecessary further testing and referral. Therefore, the PPS implementation into medical school and residency curriculums and national legal regulation for the process is a necessity in Turkey.
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Affiliation(s)
- Merve Dursun
- Department of Orthopedics and Traumatology, Ankara
University School of Medicine, Ankara, Turkey,To whom all correspondence should be addressed:
Merve Dursun, MD, Department of Orthopedics and Traumatology, Ankara University
School of Medicine, Ibn-i Sina Hospital, Hacettepe, Talatpaşa Blv No:82,
PC:06230 Altındağ/Ankara, Turkey; Tel: +90 539 557 1557;
; ORCID iD: https://orcid.org/0000-0002-9473-7948
| | - Esra Bilir
- American University of Sovereign Nations, School of
Medicine, Sacaton, AZ, USA
| | - Kubilay Kaymaz
- School of Public Health, Yale University, New Haven,
CT, USA
| | - Sibel Sakarya
- Department of Public Health, Koç University School of
Medicine, Istanbul, Turkey
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5
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Chin TJ, Lee ACL, Fulcher ML. Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey. BMJ Open Sport Exerc Med 2021; 7:e001006. [PMID: 33768962 PMCID: PMC7944969 DOI: 10.1136/bmjsem-2020-001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives To determine professional footballers’ level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification. Methods Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant. Results A total of 212 players participated (response rate=48.8%). Most respondents selected ‘To detect medical conditions that may affect performance’ and ‘To detect current injuries’ (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment’s limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216). Conclusion Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.
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Affiliation(s)
- Thomas J Chin
- Anglesea Sports Medicine, Hamilton, New Zealand.,Summit Sports Medicine, Mount Maunganui, New Zealand
| | - Arier C L Lee
- Department of Epidemiology and Biostatistics, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Mark L Fulcher
- Axis Sports Medicine Specialists, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
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6
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Lawrenz W. Keine ausreichende Evidenz für das EKG als obligater Bestandteil der sportmedizinischen Vorsorgeuntersuchung bei Kindern und Jugendlichen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00955-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Zorzi A, Cardaioli F, Cipriani A, D'Ascenzi F, Corrado D, Solmi M. Impact of exercise addiction on attitude to preparticipation evaluation and adherence to medical prescription. J Cardiovasc Med (Hagerstown) 2020; 21:772-778. [PMID: 32520862 DOI: 10.2459/jcm.0000000000000997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Identification of silent cardiovascular diseases by preparticipation evaluation (PPE) and disqualification from competitive sports have the potential to prevent sudden death but may induce adverse psychological consequences, particularly for exercise addicted athletes. We investigated the relationship between exercise addiction, attitude towards PPE and reaction to cardiovascular disease diagnosis. METHODS We invited Italian competitive athletes to participate in an online questionnaire investigating exercise addiction, opinion about mandatory PPE and potential reaction to both sports disqualification and hypothetical diagnosis of different cardiovascular diseases. RESULTS The survey was completed by 1011 athletes (75% men, median age 30 years) encompassing a wide range of sports disciplines and competition levels. According to the 'Exercise Dependence Scale-21', 6% were classified as exercise addicted. The vast majority of both exercise addicted and nonexercise addicted athletes agreed that PPE should be mandatory (92 and 96%, P = 0.17) and that the eligibility decision should be left to the sports medicine physician (82 and 89%, P = 0.08). In case a cardiovascular disease is identified, a higher proportion of exercise addicted athletes would undergo 'open-heart' surgery if this would allow resuming high-intensity sport (54 versus 31%, P < 0.001) and would continue exercising in case of diagnosis of a disease at risk of sudden death (57 versus 32%, P < 0.001). CONCLUSION Exercise addiction does not interfere with a general positive opinion about PPE, but is likely to impact on the adherence to medical prescription should a cardiovascular diagnosis be made. Exercise addiction should be taken into account when counselling athletes with newly diagnosed heart diseases.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padova, Padova
| | - Marco Solmi
- Department of Neuroscience.,Padua Neuroscience Centre, University of Padova, Padova, Italy
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8
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Franklin BA, Thompson PD, Al-Zaiti SS, Albert CM, Hivert MF, Levine BD, Lobelo F, Madan K, Sharrief AZ, Eijsvogels TMH. Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e705-e736. [PMID: 32100573 DOI: 10.1161/cir.0000000000000749] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.
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9
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Schnell F. [ECG in sportsmen: Distinguishing the normal from the pathological]. Presse Med 2019; 48:1393-1400. [PMID: 31471091 DOI: 10.1016/j.lpm.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/01/2019] [Indexed: 11/18/2022] Open
Abstract
An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete. An intense and prolonged physical activity (>4 hours of intense sport/week) can lead to a physiological electric remodeling. In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age. It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation. The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).
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Affiliation(s)
- Frédéric Schnell
- CHU de Rennes, Université de Rennes 1, hôpital Pontchaillou, service de médecine du sport, LTSI-UMR, Inserm, 1099 Rennes, France.
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10
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Vancini RL, Nikolaidis PT, Lira CABD, Vancini-Campanharo CR, Viana RB, Dos Santos Andrade M, Rosemann T, Knechtle B. Prevention of Sudden Death Related to Sport: The Science of Basic Life Support-from Theory to Practice. J Clin Med 2019; 8:jcm8040556. [PMID: 31022955 PMCID: PMC6517904 DOI: 10.3390/jcm8040556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/17/2019] [Accepted: 04/19/2019] [Indexed: 12/24/2022] Open
Abstract
The sudden cardiac arrest (CA) and death of athletes are dramatic and emotionally impacting events for health professionals, family, and society. Although the practice of sport participation improves general health, physical fitness, and quality of life, intense physical exercise can be a trigger for CA and sudden death occasionally in the presence of known or unknown cardiac disorders (mainly hypertrophic cardiomyopathy) and risk factors (environment, health style, family, and genetic). The present review found that sudden death associated with CA was not such a common event in competitive athletes, but it might be an underestimated event in recreational athletes. Thus, considering the exponential increase in sport participation, both in a recreational or competitive way, and the rate of sudden CA, knowledge of implementing prevention and treatment strategies is crucial. This includes preparation of health professionals and lay people in basic life support (BLS); screening and pre-participation assessment in sport programs and health education; and promotion for the recognition of CA and early completion of BLS and rapid access to automatic external defibrillator to improve the victim survival/prognosis. Thus, the purpose of this review is to provide for health professionals and lay people the most updated information, based on current guidelines, of how to proceed in an emergency situation associated with sudden CA of young adult athletes.
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Affiliation(s)
- Rodrigo Luiz Vancini
- Center for Physical Education and Sports, Federal University of Espírito Santo, Vitória 29075810, Brazil.
| | | | - Claudio Andre Barbosa de Lira
- Department of Physical Education, Faculty of Physical Education and Dance, Federal University of Goiás, Goiânia 74690-900, Brazil.
| | | | - Ricardo Borges Viana
- Department of Physical Education, Faculty of Physical Education and Dance, Federal University of Goiás, Goiânia 74690-900, Brazil.
| | | | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, 8091 Zurich, Switzerland.
| | - Beat Knechtle
- Institute of Primary Care, University of Zurich, 8091 Zurich, Switzerland.
- Medbase St. Gallen Am Vadianplatz, 9001 St. Gallen, Switzerland.
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11
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Ghorayeb N, Stein R, Daher DJ, Silveira ADD, Ritt LEF, Santos DFPD, Sierra APR, Herdy AH, Araújo CGSD, Colombo CSSDS, Kopiler DA, Lacerda FFRD, Lazzoli JK, Matos LDNJD, Leitão MB, Francisco RC, Alô ROB, Timerman S, Carvalho TD, Garcia TG. The Brazilian Society of Cardiology and Brazilian Society of Exercise and Sports Medicine Updated Guidelines for Sports and Exercise Cardiology - 2019. Arq Bras Cardiol 2019; 112:326-368. [PMID: 30916199 PMCID: PMC6424031 DOI: 10.5935/abc.20190048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Nabil Ghorayeb
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
- Programa de Pós-Graduação em Medicina do Esporte da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brazil
- Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE), São Paulo, SP - Brazil
| | - Ricardo Stein
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, RS - Brazil
- Vitta Centro de Bem Estar Físico, Porto Alegre, RS - Brazil
| | - Daniel Jogaib Daher
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
| | - Anderson Donelli da Silveira
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre, RS - Brazil
- Vitta Centro de Bem Estar Físico, Porto Alegre, RS - Brazil
| | - Luiz Eduardo Fonteles Ritt
- Hospital Cárdio Pulmonar, Salvador, BA - Brazil
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brazil
| | | | | | - Artur Haddad Herdy
- Instituto de Cardiologia de Santa Catarina, Florianópolis, SC - Brazil
- Clínica Cardiosport de Prevenção e Reabilitação, Florianópolis, SC - Brazil
| | | | - Cléa Simone Sabino de Souza Colombo
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
- Sports Cardiology, Cardiology Clinical Academic Group - St George's University of London,14 London - UK
| | - Daniel Arkader Kopiler
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brazil
| | - Filipe Ferrari Ribeiro de Lacerda
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brazil
| | - José Kawazoe Lazzoli
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
- Federação Internacional de Medicina do Esporte (FIMS), Lausanne - Switzerland
| | | | - Marcelo Bichels Leitão
- Sociedade Brasileira de Medicina do Esporte e do Exercício (SBMEE), São Paulo, SP - Brazil
| | - Ricardo Contesini Francisco
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
| | - Rodrigo Otávio Bougleux Alô
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital Geral de São Mateus, São Paulo, SP - Brazil
| | - Sérgio Timerman
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (InCor-FMUSP), São Paulo, SP - Brazil
- Universidade Anhembi Morumbi, Laureate International Universities, São Paulo, SP - Brazil
| | - Tales de Carvalho
- Clínica Cardiosport de Prevenção e Reabilitação, Florianópolis, SC - Brazil
- Departamento de Ergometria e Reabilitação Cardiovascular da Sociedade Brasileira de Cardiologia (DERC/SBC), Rio de Janeiro, RJ - Brazil
- Universidade do Estado de Santa Catarina (UDESC), Florianópolis, SC - Brazil
| | - Thiago Ghorayeb Garcia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brazil
- Hospital do Coração (HCor), Associação do Sanatório Sírio, São Paulo, SP - Brazil
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12
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Affiliation(s)
| | - M E W Hemels
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands.
- Radboud UMC, Nijmegen, The Netherlands.
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