The medical value and cost-effectiveness of an exercise test for sport preparticipation evaluation in asymptomatic middle-aged white male and female athletes

Possible Mechanisms for Adverse Cardiac Events Caused by Exercise-Induced Hypertension in Long-Distance Middle-Aged Runners: A Review

Sudden cardiac death (SCD) is rare among athletes. However, hypertrophic cardiomyopathy is the leading cause of SCD among those <35 years of age. Meanwhile, coronary artery disease (CAD) is the primary SCD cause among those ≥35 years of age. CAD-induced plaque ruptures are believed to be a significant cause of cardiovascular diseases in middle-aged individuals who participate in extreme long-distance running activities such as marathons. A total of 1970 articles related to EIH were identified using search terms. Out of these, 1946 studies were excluded for reasons such as arterial hypertension, exercise-induced pulmonary hypertension, the absence of exercise stress testing (EST), and a lack of relevance to EIH. The study analyzed 24 studies related to both long-distance runners with exercise-induced hypertension (EIH) and the general public. Among these, 11 studies were quasi-experimentally designed studies used in randomized controlled trials (RCTs) on long-distance runners with EIH. Additionally, 12 studies utilized cohort designs, and one study with a quasi-experimental design was conducted among the general population. Recent studies suggest that an imbalance between oxygen demand and supply due to ventricular hypertrophy may be the actual cause of cardiovascular disease, regardless of CAD. Exercising excessively over an extended period can reduce endothelial function and increase arterial stiffness, which in turn increases afterload and leads to an excessive increase in blood pressure during exercise. Exercise-induced hypertension (EIH), which increases the morbidity rate of resting hypertension and is a risk factor for cardio-cerebro-vascular diseases, is more prevalent in middle-aged long-distance runners than in runners from other age groups, and it increases the prevalence of critical arrhythmias, such as atrial fibrillation or ventricular arrhythmias. EIH is associated with angiotensin II activity, and angiotensin II receptor blockers show promising effects in middle-aged runners. Further, guidelines for preventing excessive participation in races and restricting exercise intensity and frequency would be useful. This review identifies EIH as a potential risk factor for cardiovascular diseases and describes how EIH induces SCD.

Test-retest reliability of the FitMáx©-questionnaire in a clinical and healthy population

PURPOSE

The FitMáx© was developed as a questionnaire-based instrument to estimate Cardiorespiratory Fitness (CRF) expressed as oxygen uptake at peak exercise (VO2peak). Test-retest reliability is a clinometric measurement property, which defines stability over time if multiple measurements are performed (i.e. reliability). The present study aimed to assess the test-retest reliability of the FitMáx©-questionnaire in different patient groups.

PATIENTS AND METHODS

A total of 127 cardiac, pulmonary and oncology patients and healthy subjects aged 19-84 years who completed the questionnaire twice within an average of 18 days were included for analysis. Participants were in a stable clinical situation (no acute disease or participating in a training program). To determine the test-retest reliability, the Intraclass Correlation Coefficient (ICC) and Standard Error of the Measurement (SEM) was calculated between the first (T0) and second (T1) administration of the questionnaires.

RESULTS

An excellent agreement was found between the FitMáx©-questionnaire scores at T0 and T1, with an ICC of 0.97 (SEM 1.91) in the total study population and an ICC ranging from 0.93 to 0.98 (SEM 1.52-2.27) in the individual patient groups.

CONCLUSION

The FitMáx©-questionnaire proves to be reliable and stable over time to estimate CRF of patients and healthy subjects. Trial registration NTR (Netherlands Trial Register), NL8846. Registered 25 August 2020, https://trialsearch.who.int/Trial2.aspx?TrialID=NL8846.

Characteristics of Second-Line Investigations of Middle-Aged Athletes Who Failed Preparticipation Examinations

OBJECTIVE

The role of exercise testing during preparticipation examinations (PPEs) of middle-aged athletes is uncertain. This study examined the characteristics of disqualifications after an initial PPE that includes an exercise test in competitive athletes older than 30 years. We investigated disqualification rates and reasons, second-line investigations performed, and final decisions regarding competitive sports participation.

DESIGN

Chart review.

SETTING

Sports medicine clinic.

PARTICIPANTS

Athletes aged >30 years that performed an exercise test as part of their annual PPE at our sports medicine clinic (n = 866).

INDEPENDENT VARIABLES

Age, sex, height, weight, sport type, cardiovascular risk factors, and abnormal PPE findings.

MAIN OUTCOME MEASURES

Additional investigations performed, approval/disqualification regarding competitive sports participation.

RESULTS

The initial disqualification rate of athletes was 9.8%. Three (3.6%) athletes were disqualified following questionnaire and physical examination, 19 (22.4%) because of resting electrocardiogram findings, and 65 (76.5%) following the exercise test. After additional work-up, only 5 athletes (0.4%) were ultimately found ineligible for competitive sports. From those, only 2 athletes (0.2%) were disqualified because of exercise test findings, which were episodes of supraventricular tachycardia and not ischemia-related.

CONCLUSIONS

The addition of an exercise test to the PPE of middle-aged athletes is of limited value. If exercise testing of older athletes is performed, arrhythmias are probably of higher significance than ST-T changes.

Estimating VO2peak in 18–90 Year-Old Adults: Development and Validation of the FitMáx©-Questionnaire

Purpose

Cardiorespiratory fitness (CRF) plays an essential role in health outcomes and quality of life. However, it is often not assessed nor estimated. Objective CRF assessment is costly, labour intensive and not widely available. Patient-reported outcome measures estimate CRF more cost-efficiently, but current questionnaires lack accuracy. The aim of this study is to develop a new self-reported questionnaire to estimate CRF.

Materials and Methods

The FitMáx©-questionnaire, consisting of only three questions assessing walking, stair climbing, and cycling capacity, was compared with the commonly used Duke Activity Status Index (DASI) and Veterans Specific Activity Questionnaire (VSAQ). These questionnaires were compared to peak oxygen uptake (VO_2peak) as measured with cardiopulmonary exercise testing. This study included 759 cardiac, pulmonary and oncologic patients and healthy persons aged 18‒90.

Results

FitMáx© strongly correlated (r = 0.94 (0.92‒0.95) SEE = 4.14 mL∙kg⁻¹∙min⁻¹) with measured VO_2peak. Bias between predicted and measured VO_2peak was −0.24 (−9.23‒8.75; 95% limits of agreement) mL·kg⁻¹·min⁻¹. The FitMáx© scored superiorly on correlation and SEE compared with the DASI and VSAQ, r = 0.75 (0.68‒0.80) SEE = 4.62 mL∙kg⁻¹∙min⁻¹ and r = 0.87 (0.83‒0.90) SEE = 6.75 mL∙kg⁻¹∙min⁻¹, respectively.

Conclusion

FitMáx© is a valid and accessible questionnaire to estimate CRF expressed as VO_2peak in clinical practice and shows substantial improvement compared to currently used questionnaires.

Special Article - Exercise-induced right ventricular injury or arrhythmogenic cardiomyopathy (ACM): The bright side and the dark side of the moon

There is still debate on the range of normal physiologic changes of the right ventricle or ventricular (RV) function in athletes. Genetic links to arrhythmogenic cardiomyopathy (ACM) are well-established. There is no current consensus on the importance of extensive exercise and exercise-induced injury to the RV. During the intensive exercise of endurance sports, the cardiac structures adapt to athletic load over time. Some athletes develop RV cardiomyopathy possibly caused by genetic predisposition, whilst others develop arrhythmias from the RV. Endurance sports lead to increased volume and pressure load in both ventricles and increased myocardial mass. The extent of volume increase and changes in myocardial structure contribute to impairment of RV function and pose a challenge in cardiovascular sports medicine. Genetic predisposition to ACM may play an important role in the risk of sudden cardiac death of athletes. In this review, we discuss and evaluate existing results and opinions. Intensive training in competitive dynamic/power and endurance sports leads to specific RV adaptation, but physiological adaptation without genetic predisposition does not necessarily lead to severe complications in endurance sports. Discriminating between physiological adaptation and pathological form of ACM or RV impairment provoked by reinforced exercise presents a challenge to clinical sports cardiologists.

Comparison of cardiovascular screening guidelines for middle-aged/older adults

PURPOSE

Although both European (EACPR) and American (ACSM) Scientific Societies have devised cardiovascular protocols for the assessment of "middle-aged/older" individuals who are about to participate in sports or physical exercise, there are no data regarding the guidelines' sensitivity of these measures. The aim of this study was to compare the outcomes of different international screening protocols.

METHODS

This observational cross-sectional study evaluated 525 subjects (80% males; median age 50 [35-85] years) seeking medical certification before participating in sports or regular exercise. The screening protocol consisted in completing a personal history profile, a physical examination, a resting ECG, a maximal exercise test, and, when required, additional instrumental evaluations. The effectiveness of the current EACPR as well as the former and new ACSM guidelines was thereby analyzed.

RESULTS

The full screening protocol uncovered 100 previously undetected cardiovascular conditions (main pathologies detected: 21 coronary artery disease (CAD), 14 arterial hypertension, 38 complex arrhythmias). When the European guideline was used, 49% of these conditions went undetected, including 10 CAD. When the former American guideline was used, 29% (6 CAD) went undetected; when the recently updated edition was used, 50% including 11 CAD went undetected.

CONCLUSION

The former ACSM guideline demonstrated a higher diagnostic sensitivity than the newer version and the EACPR guideline. Current screening protocols might be adapted for subjects performing high-intensity exercise due to their higher risk for cardiovascular and exercise-associated adverse events. The use of an incremental ECG-monitored maximal exercise test seems to improve these screening outcomes.

[Place of the exercise stress test at the sportsman]

Is the stress test still part of the useful examinations in the detection of risk heart disease in sports subjects? Should we continue to use it as a surveillance examination in coronary sports patients? Meta-analysis, considering a ST subshift of more than 1mm as a criterion for positivity, underline the low prevalence of abnormal examinations and a significant rate of false-positives. But for the diagnosis of coronary artery disease, it is mainly the evolution of the ST segment to effort or recovery and the occurrence of stress arrhythmias that detect true positivity. When coronary risk is more important (presence of risk factors, resumption of sport, intense and prolonged efforts), it seems lawful to recommend such a review on a regular basis among men over 40 years of age with two risk factors but Also among veterans taking up sport after a period of prolonged inactivity. For the asymptomatic coronary athlete the stress test remains at the centre of the final decision for the resumption of a sport in competition irrespective of the method of revascularization. Of course the stress test, even inevitable, remains flawed in the detection of coronary artery disease in the asymptomatic athlete. However, it provides additional information on the condition of being maximal, and attaching importance to arrhythmias, the tensional profile and the maximum power developed in addition to the ST segment's only study.

Assessing the value of screening tools: reviewing the challenges and opportunities of cost-effectiveness analysis

Background

Screening is an important part of preventive medicine. Ideally, screening tools identify patients early enough to provide treatment and avoid or reduce symptoms and other consequences, improving health outcomes of the population at a reasonable cost. Cost-effectiveness analyses combine the expected benefits and costs of interventions and can be used to assess the value of screening tools.

Objective

This review seeks to evaluate the latest cost-effectiveness analyses on screening tools to identify the current challenges encountered and potential methods to overcome them.

Methods

A systematic literature search of EMBASE and MEDLINE identified cost-effectiveness analyses of screening tools published in 2017. Data extracted included the population, disease, screening tools, comparators, perspective, time horizon, discounting, and outcomes. Challenges and methodological suggestions were narratively synthesized.

Results

Four key categories were identified: screening pathways, pre-symptomatic disease, treatment outcomes, and non-health benefits. Not all studies included treatment outcomes; 15 studies (22%) did not include treatment following diagnosis. Quality-adjusted life years were used by 35 (51.4%) as the main outcome. Studies that undertook a societal perspective did not report non-health benefits and costs consistently. Two important challenges identified were (i) estimating the sojourn time, i.e., the time between when a patient can be identified by screening tests and when they would have been identified due to symptoms, and (ii) estimating the treatment effect and progression rates of patients identified early.

Conclusions

To capture all important costs and outcomes of a screening tool, screening pathways should be modeled including patient treatment. Also, false positive and false negative patients are likely to have important costs and consequences and should be included in the analysis. As these patients are difficult to identify in regular data sources, common treatment patterns should be used to determine how these patients are likely to be treated. It is important that assumptions are clearly indicated and that the consequences of these assumptions are tested in sensitivity analyses, particularly the assumptions of independence of consecutive tests and the level of patient and provider compliance to guidelines and sojourn times. As data is rarely available regarding the progression of undiagnosed patients, extrapolation from diagnosed patients may be necessary.