Should Pre-participation Cardiovascular Screening for Competitive Athletes be Introduced in Australia? A Timely Debate in a Sport-loving Nation

Apicolateral bulge: A potential mimic of arrhythmogenic right ventricular cardiomyopathy in a professional athlete-A case report and literature review

Soccer is the most popular sport in the world, with over 265 million active players and approximately 0.05% professional players worldwide. The Fédération Internationale de Football Association (FIFA) has made preparticipation screening recommendations which involve electrocardiography and echocardiography being performed prior to international competition. The aim of preparticipation cardiovascular screening in young athletes is to detect asymptomatic individuals with cardiovascular disease at risk of sudden cardiac death (SCD). The incidence of SCD in young athletes (age≤ 35 years) is 0.6-3.6 in 100,000 persons/year, with most deaths due to cardiovascular causes. Arrhythmogenic right ventricular cardiomyopathy (ARVC) is one of the leading causes of SCD in young athletes. It is a genetic disease characterized by progressive fibrofatty replacement of the myocardium with variable phenotypic expression. Exercise-induced cardiac remodeling in conjunction with extensive T-wave inversion raises concern for ARVC. This case report and literature review explores a potential mimic for ARVC, the role of cardiovascular screening in sport, and the use of a multimodality approach for risk stratification and management.

Promoting Heart Health: Raising Screening Awareness at a Brisbane Medical Center

Background Atherosclerotic cardiovascular disease (CVD) is a largely preventable, chronic, and progressive medical condition. There appears to be a general lack of knowledge about CVD prevention in the community. This pilot study was carried out to investigate the level of knowledge of CVD prevention among patients visiting a general practitioner (GP) practice in Brisbane. Aim To investigate the level of knowledge of CVD prevention among people visiting a local medical clinic in Brisbane, and to identify the factors responsible for any knowledge deficits. Material and methods A cross-sectional survey was conducted among Brisbane residents aged 45 years and older visiting a local medical center. This study surveyed 105 Australian individuals via an online survey or a hard copy questionnaire for those without online access. A combination of closed-ended questions and multiple-choice questionnaires was utilized to collect the data. Questions were formulated to assess the level of knowledge of CVD prevention among this demographic, exploring the subjects' awareness of the screening program, their adherence, factors behind non-adherence, and understanding the influence of education level and occupation on adherence. Results A total of 105 Brisbane adults completed the survey, of which 56 (53.3%) were male. The study found that 61 (58.1%) of the participants were aware of the CVD prevention screening program, but only 22 (21.9%) were compliant with it. Twelve (11.4%) participants attended these preventive screenings less frequently than recommended, while the remaining 69 (66.6%) had never undergone cardiovascular health checks. Conclusion Analysis of data from this population suggests that there is a knowledge deficit among Brisbane residents regarding CVD prevention programs. Enhanced efforts by clinicians to make patients aware of these screening tools and to employ early intervention strategies, especially lifestyle choices at an earlier age, would help lower the burden of CVD.

A comprehensive electrocardiographic analysis for young athletes

ECG-based differences between athletes and sedentary adolescents are a frequently investigated subject in sports medicine. Especially, training-induced ECG variations are common in adult athletes and sustained training often leads to anatomical changes in the heart that can yield abnormalities in ECG. Therefore, ECG screening in athletes is important in diagnosis of cardiac problems of young athletes. The present work investigated the ECG characteristics of young athletes in terms of both gender and sedentary healthy young control group differences. Besides comparison between groups, analysis parameters were also investigated within the groups using correlation analysis. ECG characteristics were extracted using wavelet transform-based adaptive algorithms. Results showed that ECGs of athletes demonstrate differences related to gender and compared to young sedentary. Athletes had significantly lower heart rate; higher QTc, P, and T amplitudes; ST segment; and ST, QT, and RR intervals compared to control group (p < 0.05). Proposed new parameter, namely "scalogram" of each wave, was lower in male athletes compared to other groups (p < 0.05). Negative correlation between T wave amplitude and RR interval could be an indicator of long QT syndrome for male athletes. Furthermore, prolongation of QRS interval in athletes could be the underlying reason of changes in T wave amplitude. Findings of this study can propose indicators for understanding the possible diseases as well as help evaluate the sudden changes in athlete's heart.

What May the Future Hold for Sports Cardiology?

The field of sports cardiology has advanced significantly over recent times. It has incorporated clinical and research advances in cardiac imaging, electrophysiology and exercise physiology to enable better diagnostic and therapeutic management of our patients. One important endeavour has been to try and better differentiate athletic cardiac remodelling from inherited cardiomyopathies and other pathologies. Whilst our diagnostic tools have improved, there have also been errors resulting from assumptions that the pathological traits observed in the general population would be generalisable to athletic populations. However, we have learnt that athletes with hypertrophic cardiomyopathy, for example, have many unique features when compared with non-athletic patients with hypertrophic cardiomyopathy. We are learning the limitations of cross-sectional observations and a greater number of prospective studies have been initiated which should enable us to more confidently interrogate the associations between exercise, cardiac remodelling and clinical outcomes. This review of the field enables some of the world's experts in sports cardiology to reflect on where there is a need for research focus to advance knowledge and clinical care in sports cardiology.

Correlation between ECG changes and early left ventricular remodeling in preadolescent footballers

The aim of this study was to assess the early electrocardiogram (ECG) changes induced by physical training in preadolescent elite footballers. This study included 94 preadolescent highly trained male footballers (FG) competing in Serbian Football League (minimum of 7 training hours/week) and 47 age-matched healthy male controls (less than 2 training hours/week) (CG). They were screened by ECG and echocardiography at a tertiary referral cardio center. Sokolow-Lyon index was used as a voltage electrocardiographic criterion for left ventricular hypertrophy diagnosis. Characteristic ECG intervals and voltage were compared and reference range was given for preadolescent footballers. Highly significant differences between FG and CG were registered in all ECG parameters: P-wave voltage (p < 0.001), S-wave (V1 or V2 lead) voltage (p < 0.001), R-wave (V5 and V6 lead) voltage (p < 0.001), ECG sum of S V_1-2 + R V_5-6 (p < 0.001), T-wave voltage (p < 0.001), QRS complex duration (p < 0.001), T-wave duration (p < 0.001), QTc interval duration (p < 0.001), and R/T ratio (p < 0.001). No differences were found in PQ interval duration between these two groups (p > 0.05). During 6-year follow-up period, there was no adverse cardiac event in these footballers. None of them expressed pathological ECG changes. Benign ECG changes are presented in the early stage of athlete's heart remodeling, but they are not related to pathological ECG changes and they should be regarded as ECG pattern of LV remodeling.

The right ventricle following prolonged endurance exercise: are we overlooking the more important side of the heart? A meta-analysis

AIMS

Prolonged endurance exercise is associated with elevated biomarkers associated with myocardial damage and modest evidence of left ventricular (LV) dysfunction. Recent studies have reported more profound effects on right ventricular (RV) function following endurance exercise. We performed a meta-analysis of studies reporting RV function pre-endurance and postendurance exercise.

METHODS

We performed a search of peer-reviewed studies with the criteria for inclusion in the analysis being (1) healthy adult participants; (2) studies examining RV function following an event of at least 90 min duration; (3) studies reporting RV fractional area change (RVFAC), RV strain (S), RV ejection fraction (RVEF) or tricuspid annular plane systolic excursion (TAPSE) and (4) studies evaluating RV function immediately (<1 h) following exercise.

RESULTS

Fourteen studies were included with 329 participants. A random-effects meta-analysis revealed significant impairments of RV function when assessed by RVFAC (weighted mean difference (WMD) -5.78%, 95% CI -7.09% to -4.46%), S (WMD 3.71%, 95% CI 2.79% to 4.63%), RVEF (WMD -7.05%, 95% CI -12.3% to -1.8%) and TAPSE (WMD -4.77 mm, 95% CI -8.3 to -1.24 mm). Modest RV dilation was evident in studies reporting RV systolic area postexercise (WMD 1.79 cm(2), 95% CI 0.5 to 3.08 cm(2)). In contrast, no postexercise changes in LV systolic function (expressed as LVFAC or LVEF) were observed in the included studies (standardised mean difference 0.03%, 95% CI -0.13% to 0.18%).

CONCLUSIONS

Intense prolonged exercise is associated with a measurable reduction in RV function while LV function is relatively unaffected. Future studies should examine the potential clinical consequences of repeated prolonged endurance exercise on the right ventricle.

Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study

Most of the available data on the cardiovascular screening of athletes come from Italy, with fewer records being available outside of Italy and for non-Caucasian populations. The goals of the SMILE project (Sport Medicine Intervention to save Lives through ECG) are to evaluate the usefulness of 12-lead ECGs for the detection of cardiac diseases in athletes from three European countries and one African country and to estimate how many second-level examinations are needed subsequent to the initial screening in order to classify athletes with abnormal characteristics. A digital network consisting of Sport Centres and second and third opinion centres was set up in Greece, Germany, France and Algeria. Standard digital data input was carried out through the application of 12-lead ECGs, Bethesda questionnaires and physical examinations. Two hundred ninety-three of the 6,634 consecutive athletes required further evaluation, mostly (88.4 %) as a consequence of abnormal ECGs. After careful evaluation, 237 were determined to be healthy or apparently healthy, while 56 athletes were found to have cardiac disorders and were thus disqualified from active participation in sports. There was a large difference in the prevalence of diseases detected in Europe as compared with Algeria (0.23 and 4.01 %, respectively). Our data confirmed the noteworthy value of 12-lead resting ECGs as compared with other first-level evaluations, especially in athletes with asymptomatic cardiac diseases. Its value seems to have been even higher in Algeria than in the European countries. The establishment of a digital network of Sport Centres for second/third opinions in conjunction with the use of standard digital data input seems to be a valuable means for increasing the effectiveness of screening.