Coronary atherosclerosis in apparently healthy master athletes discovered during pre-PARTECIPATION screening. Role of coronary CT angiography (CCTA)

Value of preparticipation cardiovascular evaluation of master athletes by self-reported symptoms and cardiovascular risk-score

The risk of sudden cardiac death (SCD) is increased during endurance competitive sports. Coronary artery disease (CAD) is the most common cause of SCD in master athletes ≥ 35 years old (MAs). To reduce the risk of SCD self-assessment of symptoms by questionnaire, and evaluation of cardiovascular risk-score, are recommended as pre-participation cardiovascular evaluation (PCVE). We aimed to examine whether PCVE predicts CVD in MAs with or without increased risk as measured by validated score instruments.

We performed a single-site observational cohort study of healthy MAs based on findings at PCVE. They were allocated in two different groups: those MAs with reported symptoms on the questionnaire and/or with elevated cardiovascular risk score were allocated to a symptom group (SG), while MAs with no symptoms, nor raised risk score were defined as control group (CG). Thereafter, all were examined with extended examinations: resting-ECG, cardiorespiratory exercise testing and echocardiography.

Total, 81 (18 women) MAs participated in the study. There were no differences at baseline between SG (n = 39) and CG (n = 42); sex (p = 0.11), age (55.0 ± 9.8 vs. 51.9 ± 11.1 years; p = 0.18), maximal oxygen uptake (49.8 ± 7.6 vs. 51.6 ± 7.0 ml/kg/min; p = 0.26), resting heart rate (61.4 ± 12.8 vs. 60.2 ± 11.0/min; p = 0.66), training hours/week (7.0 ± 3.2 vs. 7.1 ± 3.1; p = 0.88). After further examination, sixteen (20%) MAs were found with CVD: 12 in SG, 4 in CG (p = 0.024). The negative predictive value and specificity of the PCVE were 90% and 58%, respectively.

Negative findings on PCVE by questionnaire and cardiovascular risk-score may be a strategy to exclude subjects from preparticipation screening, thus saving resources.

The role of coronary CT angiography in athletes

The sudden death of a young or high-level athlete or adolescent during recreational sports is one of the events with the greatest impact on public opinion in modern society. Sudden cardiac death (SCD) is the principal medical cause of death in athletes and can be the first and last clinical presentation of underlying disease. To prevent such episodes, pre-participation screening has been introduced in many countries to guarantee cardiovascular safety during sports and has become a common target among medical sports/governing organizations. Different cardiac conditions may cause SCD, with incidence depending on definition, evaluation methods, and studied populations, and a prevalence and etiology changing according to the age of athletes, with CAD most frequent in master athletes, while coronary anomalies and non-ischemic causes prevalent in young. To detect silent underlying causes early would be of considerable clinical value. This review summarizes the pre-participation screening in athletes, the specialist agonistic suitability visit performed in Italy, the anatomical characteristics of malignant coronary anomalies, and finally, the role of coronary CT angiography in such arena. In particular, the anatomical conditions suggesting potential disqualification from sport, the post-treatment follow-up to reintegrate young athletes, the diagnostic workflow to rule-out CAD in master athletes, and their clinical management are analyzed.

The role of cardiac computed tomography in sports cardiology: back to the future!

In recent years, the role of pre-participation evaluation (PPE) in the prevention of sudden cardiac death in competitive athletes has become evident. Most physicians routinely supplement assessment by resting electrocardiogram with imaging techniques, such as echocardiography. The primary goal of imaging in the clinical assessment of competitive athletes is to exclude cardiovascular conditions associated with adverse outcomes. Cardiac computed tomography is emerging as an important technique for stratifying cardiovascular risk and assessing coronary artery disease (CAD), particularly in master athletes. Conversely, in young athletes, this technique has the best non-invasive coronary artery resolution and provides valuable details on coronary artery anatomy. Recent technical developments have brought about a dramatic reduction in radiation exposure, a major drawback of this diagnostic method; nowadays cardiac computed tomography may be performed at a dose of barely one millisievert. The present review provides a practical guide for the use of cardiac computed tomography in the PPE of competitive athletes, with a specific focus on its value for detecting congenital coronary anomalies and CAD in young and master athletes, respectively.

Advanced cardiac imaging in athlete's heart: unravelling the grey zone between physiologic adaptation and pathology

Over the last decades, interest toward athlete's heart has progressively increased, leading to improve the knowledge on exercise-induced heart modifications. Sport may act as a trigger for life-threatening arrhythmias in patients with structural or electrical abnormalities, hence requiring to improve the diagnostic capability to differentiate physiological from pathological remodeling. Pathological alterations are often subtle at the initial stages; therefore, the challenge is to promptly identify athletes at risk of sudden cardiac death during the pre-participation screening protocols. Advanced imaging modalities such as coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) can non-invasively depict coronary vessels and provide a deep morpho-functional and structural characterization of the myocardium, in order to rule out pathological life threatening alterations, which may overlap with athletes' heart remodeling. The purpose of the present narrative review is to provide an overview of most frequent diagnostic challenges, defining the boundaries between athlete's heart remodeling and pathological structural alteration with a focus on the role and importance of CCTA and CMR.

Age-dependent diagnostic yield of echocardiography as a second-line diagnostic investigation in athletes with abnormalities at preparticipation screening

AIMS

Systematic pre-participation screening of subjects practicing sports activity has the potential to identify athletes at risk of sudden cardiac death. However, limited evidence are present concerning the yield of echocardiography as a second-line exam in athletes with abnormal pre-participation screening.

METHODS

Consecutive athletes were screened (2011-2017) in a community-based sports medicine center in Tuscany, with familial history, physical examination and ECG. Patients with abnormal/>1 borderline ECG findings, symptoms/signs of cardiovascular diseases, cardiovascular risk factors or family history of juvenile/genetic cardiac disease underwent echocardiography.

RESULTS

A total of 30109 athletes (age 21 [15;31]) were evaluated. Of these, 6234 (21%) were aged 8-11 years, 18309 (61%) 12-18 years, 4442 (15%) 19-35 years, 1124 (4%) >35 years. A total of 2569 (9%) athletes were addressed to echocardiography. Referral rates increased significantly with age (5% in preadolescents to 38% in master athletes, P< 0.01). Subclinical heart diseases were found in 290/30109 (0.8%) and were common >35 years (135/1124, 11%), but rare at 19-35 years (91/4442, 2%), very rare <18 years (64/24 543, 0.2%; P< 0.01). Seventy-four (0.3%) athletes were disqualified because of the structural alterations identified, 29 (0.1%) with cardiac structural diseases at risk for sudden death.

CONCLUSIONS

Italian community-based pre-participation screening showed an age-dependent yield, with a three-fold increase in referral in athletes >35 years. Subclinical structural abnormalities potentially predisposing to sudden death were rare (0.01%), mostly in post-pubertal and senior athletes. Age-specific pre-participation screening protocols may help optimize resources and improve specificity.

The role of modern cardiovascular imaging in (suspected) coronary artery disease in competitive athletes

This overview addresses different non-invasive imaging methods in diagnosing CAD before clearing the athlete for participation in sports activity. Keep in mind the risks and benefits of exercising for the competitive athlete and to use the SCORE-information as a first evaluation tool. It is essential to gather relevant information and to complement anatomical evaluations with functional evaluations. Exercise testing also has an added value in athletes as it will inform both the physician and the athlete on the aerobic fitness of the individual, a key factor in risk assessment.

SIRM-SIC appropriateness criteria for the use of Cardiac Computed Tomography. Part 1: Congenital heart diseases, primary prevention, risk assessment before surgery, suspected CAD in symptomatic patients, plaque and epicardial adipose tissue characterization, and functional assessment of stenosis

In the past 20 years, Cardiac Computed Tomography (CCT) has become a pivotal technique for the noninvasive diagnostic work-up of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Recent large multicenter randomized clinical trials documented the high prognostic value of CCT and its capability to increase the cost-effectiveness of the management of patients with suspected CAD. In the meantime, CCT, initially perceived as a simple non-invasive technique for studying coronary anatomy, has transformed into a multiparametric "one-stop-shop" approach able to investigate the heart in a comprehensive way, including functional, structural and pathophysiological biomarkers. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Medical and Interventional Radiology (SIRM) and by the Italian Society of Cardiology (SIC), represents the first of two consensus documents collecting the expert opinion of Radiologists and Cardiologists about current appropriate use of CCT.

The role of cardiac computed tomography in pre-participation screening of mature athletes

The overwhelming majority of sports-related sudden cardiac deaths in mature athletes is attributed to coronary artery disease (CAD). Coronary plaques of mature athletes appear to be more calcified compared to sedentary individuals and thus may be more stable and less likely to be associated with an acute coronary event. Cardiac computed tomography (CT), including unenhanced CT for coronary artery calcium scoring (CACS) and contrast-enhanced coronary CT angiography, is characterized by very high negative predictive value to rule out CAD. Cardiac CT has been shown to have additional diagnostic value for detection of CAD in athletes over and above exercise electrocardiogram. Moreover, measurement of CACS possibly enables a more precise cardiovascular risk stratification of mature athletes. The main advantage of cardiac CT is its noninvasive nature. Although cardiac CT appears to increase the overall cost of cardiac examinations, this additional cost is much lower than the cost of unnecessary invasive coronary angiographies that would be performed in case of false positive results of exercise electrocardiograms. Radiation exposure may not be a major concern for the application of this modality to pre-participation screening of athletes, since recent technical advancements have resulted in low radiation dose of cardiac CT.Highlights Coronary computed tomography angiography can be used in pre-participation screening of mature athletes to increase the negative predictive value for excluding coronary artery disease.The identification of coronary artery calcium score = 0 in an athlete can improve risk stratification, since this athlete can be reasonably managed as an individual with low cardiovascular risk.

Cardiovascular risk among ultra-endurance runners

BACKGROUND

Our objective was to determine the prevalence and clinical correlates of conventional cardiovascular risk factors among ultra-endurance marathon runners.

METHODS

An electronic internet survey to characterize modifiable cardiovascular risk factors including diabetes, hypertension, dyslipidemia, tobacco exposure and obesity (BMI >30) among competitive ultra-endurance runners.

RESULTS

Among 290 respondents (mean ± SD, 42 ± 11 years, 31.4% female), 106 (36.6%) had at least one established cardiovascular risk factor. Female sex, younger age and participation in competitive high school or collegiate sports were associated with freedom from cardiovascular risk factors. There were no significant associations between risk factor status and either hours per week of running training (risk factor negative = 10 ±7 vs. risk factor positive = 11 ± 8 hours, p=0.42) or years of ultra-endurance competition (6 ± 8 vs. 7 ± 9 years, p=0.38). Runners with at least one cardiovascular risk factor were more likely to have had personal or peer concerns about excessive alcohol use.

CONCLUSIONS

Conventional cardiovascular risk factors are common among ultra-endurance runners. Early life participation in competitive sports, rather than adult exercise habits, is associated with freedom from the development of cardiovascular risk factors during middle age. Determining mechanistic explanations for the legacy effect of early life exercise as a means to reduce cardiovascular risk among aging athletes represents an important area of future work.

Sudden Cardiac Death in Athletes in Italy during 2019: Internet-Based Epidemiological Research

Background and objectives: An Italian nationwide pre-participation screening approach for prevention of sudden cardiac death in athletes (SCD-A) in competitive sportspeople showed promising results but did not achieve international consensus, due to cost-effectiveness and the shortfall of a monitoring plan. From this perspective, we tried to provide an epidemiological update of SCD-A in Italy through a year-long internet-based search. Materials and Methods: One year-long Google search was performed using mandatory and non-mandatory keywords. Data were collected according to prevalent SCD-A definition and matched with sport-related figures from Italian National Institute of Statistics (ISTAT) and Italian National Olympic Committee (CONI). Results: Ninety-eight cases of SCD-A in 2019 were identified (48.0% competitive, 52.0% non-competitive athletes). Male/female ratio was 13:1. The most common sports were soccer (33.7%), athletics (15.3%) and fitness (13.3%). A conclusive diagnosis was achieved only in 37 cases (33 of cardiac origin), with the leading diagnosis being coronary artery disease in 27 and a notably higher occurrence among master athletes. Combining these findings with ISTAT and CONI data, the SCD-A incidence rate in the whole Italian sport population was found to be 0.47/100,000 persons per year (1.00/100,000 in the competitive and 0.32/100,000 in the non-competitive population). The relative risk of SCD-A is 3.1 (CI 2.1–4.7; p < 0.0001) for competitive compared to non-competitive athletes; 9.9 for male (CI 4.6–21.4; p < 0.0001) with respect to female. Conclusions: We provided an updated incidence rate of SCD-A in both competitive and non-competitive sport in Italy. A higher risk of SCD-A among competitive and male athletes was confirmed, thus corroborating the value of Italian pre-participation screening in this population.

Symptoms Preceding Sports-Related Sudden Cardiac Death in Persons Aged 1-49 Years

PURPOSE OF REVIEW

Sports-related sudden cardiac death (Sr-SCD) is a leading natural cause of death in young athletes. To prevent Sr-SCD in athletes, it is important to identify individuals at risk. This review sought to summarize the current knowledge of symptoms prior to Sr-SCD in athletes aged 1-49 years.

RECENT FINDINGS

Cardiovascular screening of athletes is a subject of interest. However, the cost of ECG screening in a young population is relatively high compared to potential benefits, and systematic screening of athletes is heavily debated. In the background population, both cardiac and non-specific symptoms are often present prior to SCD. Both cardiac and non-specific symptoms are present in up to 74% prior to Sr-SCD. The main symptoms are syncope, chest pain, palpitations and dizziness. Knowledge of symptoms could potentially be used in combination with non-invasive prediction models to prevent Sr-SCD and treat athletes at risk.

Is extensive cardiopulmonary screening useful in athletes with previous asymptomatic or mild SARS-CoV-2 infection?

OBJECTIVE

During the COVID-19 pandemic, it is essential to understand if and how to screen SARS-CoV-2-positive athletes to safely resume training and competitions. The aim of this study is to understand which investigations are useful in a screening protocol aimed at protecting health but also avoiding inappropriate examinations.

METHODS

We conducted a cohort study of a professional soccer team that is based on an extensive screening protocol for resuming training during the COVID-19 pandemic. It included personal history, antigen swabs, blood tests, spirometry, resting/stress-test ECG with oxygen saturation monitoring, echocardiogram, Holter and chest CT. We also compared the findings with prior data from the same subjects before infection and with data from SARS-CoV-2-negative players.

RESULTS

None of the players had positive swab and/or anti-SARS-CoV-2 IgM class antibodies. Out of 30 players, 18 (60%) had IgG class antibodies. None had suffered severe SARS-CoV-2-related disease, 12 (66.7%) had complained of mild COVID-19-related symptoms and 6 (33.3%) were asymptomatic. None of the players we examined revealed significant cardiovascular abnormalities after clinical recovery. A mild reduction in spirometry parameters versus pre-COVID-19 values was observed in all athletes, but it was statistically significant (p<0.05) only in SARS-CoV-2-positive athletes. One SARS-CoV-2-positive player showed increased troponin I level, but extensive investigation did not show signs of myocardial damage.

CONCLUSION

In this small cohort of athletes with previous asymptomatic/mild SARS-CoV-2 infection, a comprehensive screening protocol including blood tests, spirometry, resting ECG, stress-test ECG with oxygen saturation monitoring and echocardiogram did not identify relevant anomalies. While larger studies are needed, extensive cardiorespiratory and haematological screening in athletes with asymptomatic/mild SARS-CoV-2 infection appears unnecessary.

ECG criteria for the detection of high-risk cardiovascular conditions in master athletes

Objective

Structured electrocardiography (ECG) analysis is used to screen athletes for high-risk cardiovascular conditions (HRCC) to prevent sudden cardiac death. ECG criteria have been specified and recommended for use in young athletes ≤ 35 years. However, it is unclear whether these ECG criteria can also be applied to master athletes >35 years.

Aim

The purpose of this study was to test whether the existing ECG criteria for detecting HRCC in young athletes can be applied to master athletes.

Methods

We conducted a cross-sectional study among athletes >35 years screened for HRCC between 2006 and 2010. We performed a blinded retrospective analysis of master athletes’ ECGs, separately applying European Society of Cardiology (ESC)-2005, Seattle, and International criteria. HRCC were defined using recommendations from the international cardiac societies American Heart Association and American College of Cardiology, and ESC, based on ECG screening and cardiovascular evaluation (CVE).

Results

We included 2578 master athletes in the study, of whom 494 had initial screening abnormalities mandating CVE. Atrial enlargement (109, 4.1%) and left ventricular hypertrophy (98, 3.8%) were the most common ECG abnormalities found using the ESC-2005 or Seattle criteria. Applying the International criteria, ST-segment deviation (66, 2.6%), and T-wave inversion (58, 2.2%) were most frequent. The ESC-2005 criteria detected more HRCC (46, 1.8%) compared with the Seattle (36, 1.4%) and International criteria (33, 1.3%). The most frequently detected HRCC was coronary artery disease (24, 0.9%).

Conclusion

ECG criteria recommended for use in young athletes can be applied to master athletes’ ECGs to detect HRCC. The ESC-2005 criteria had the highest sensitivity for detecting HRCC among master athletes.