Sports and Exercise Cardiology in the United States

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Intermittent fasting and changes in clinical risk scores: Secondary analysis of a randomized controlled trial

Background

Intermittent fasting may increase longevity and lower cardiometabolic risk. This study evaluated whether fasting modifies clinical risk scores for mortality [i.e., Intermountain Mortality Risk Score (IMRS)] or chronic diseases [e.g., Pooled Cohort Risk Equations (PCRE), Intermountain Chronic Disease score (ICHRON)].

Methods and results

Subjects (N = 71) completing the WONDERFUL trial were aged 21-70 years, had ≥1 metabolic syndrome criteria, elevated cholesterol, and no anti-diabetes medications, statins, or chronic diseases. The intermittent fasting arm underwent 24-h water-only fasting twice-per-week for 4 weeks and once-per-week for 22 weeks (26 weeks total). Analyses examined the IMRS change score at 26 weeks vs. baseline between intermittent fasting (n = 38) and ad libitum controls (n = 33), and change scores for PCRE, ICHRON, HOMA-IR, and a metabolic syndrome score (MSS). Age averaged 49 years; 65% were female. Intermittent fasting increased IMRS (0.78 ± 2.14 vs. controls: -0.61 ± 2.56; p = 0.010) but interacted with baseline IMRS (p-interaction = 0.010) to reduce HOMA-IR (but not MSS) more in subjects with higher baseline IMRS (median HOMA-IR change: fasters, -0.95; controls, +0.05) vs. lower baseline IMRS (-0.29 vs. -0.32, respectively). Intermittent fasting reduced ICHRON (-0.92 ± 2.96 vs. 0.58 ± 3.07; p = 0.035) and tended to reduce PCRE (-0.20 ± 0.22 vs. -0.14 ± 0.21; p = 0.054).

Conclusions

Intermittent fasting increased 1-year IMRS mortality risk, but decreased 10-year chronic disease risk (PCRE and ICHRON). It also reduced HOMA-IR more in subjects with higher baseline IMRS. Increased IMRS suggests fasting may elevate short-term mortality risk as a central trigger for myriad physiological responses that elicit long-term health improvements. Increased IMRS may also reveal short-term fasting-induced safety concerns.

The Relationship between Changes in MYBPC3 Single-Nucleotide Polymorphism-Associated Metabolites and Elite Athletes' Adaptive Cardiac Function

Athletic performance is a multifactorial trait influenced by a complex interaction of environmental and genetic factors. Over the last decades, understanding and improving elite athletes' endurance and performance has become a real challenge for scientists. Significant tools include but are not limited to the development of molecular methods for talent identification, personalized exercise training, dietary requirements, prevention of exercise-related diseases, as well as the recognition of the structure and function of the genome in elite athletes. Investigating the genetic markers and phenotypes has become critical for elite endurance surveillance. The identification of genetic variants contributing to a predisposition for excellence in certain types of athletic activities has been difficult despite the relatively high genetic inheritance of athlete status. Metabolomics can potentially represent a useful approach for gaining a thorough understanding of various physiological states and for clarifying disorders caused by strength-endurance physical exercise. Based on a previous GWAS study, this manuscript aims to discuss the association of specific single-nucleotide polymorphisms (SNPs) located in the MYBPC3 gene encoding for cardiac MyBP-C protein with endurance athlete status. MYBPC3 is linked to elite athlete heart remodeling during or after exercise, but it could also be linked to the phenotype of cardiac hypertrophy (HCM). To make the distinction between both phenotypes, specific metabolites that are influenced by variants in the MYBPC3 gene are analyzed in relation to elite athletic performance and HCM. These include theophylline, ursodeoxycholate, quinate, and decanoyl-carnitine. According to the analysis of effect size, theophylline, quinate, and decanoyl carnitine increase with endurance while decreasing with cardiovascular disease, whereas ursodeoxycholate increases with cardiovascular disease. In conclusion, and based on our metabolomics data, the specific effects on athletic performance for each MYBPC3 SNP-associated metabolite are discussed.

Preparticipation Cardiovascular Screening: An Infrastructure Assessment in Collegiate Athletics

OBJECTIVE

To assess the available infrastructure for secondary testing after preparticipation cardiovascular screening of collegiate athletes.

DESIGN

Cross-sectional study.

SETTING

National Collegiate Athletic Association (NCAA) athletic programs PARTICIPANTS:: Team physicians.

INTERVENTIONS

Online survey distributed by the NCAA and American Medical Society for Sports Medicine.

MAIN OUTCOME MEASURES

Availability of secondary cardiovascular diagnostic testing and services.

RESULTS

Team physicians from 235 schools completed the assessment, representing 21% of all NCAA schools. Ninety (38.3%) NCAA team physicians reported screening athletes using electrocardiogram (ECG). Division I schools were more likely than Division II and III schools to perform both screening ECG (RR, 2.38, P < 0.0001) and echocardiogram (RR, 2.83, P = 0.01). More than 97% of schools had access to resting echocardiogram, stress ECG/echocardiogram, and Holter monitoring within 25 miles with no significant variability between divisions, regions, or size of undergraduate student body. Cardiac magnetic resonance imaging and electrophysiology studies were available within 25 miles of more than 80% of schools, and genetics testing was available within 25 miles for 64.8%.

CONCLUSIONS

Secondary testing for cardiovascular abnormalities seems to be readily available for NCAA athletes, regardless of division, region, or school size.

Metabolic profiling of elite athletes with different cardiovascular demand

Intensive exercise of elite athletes can lead to physiological alterations in the cardiovascular system in response to increased stroke volume and blood pressure, known collectively as cardiovascular demand (CD). This study aimed to compare metabolic differences in elite athletes with high vs low/moderate CD and to reveal their underlying metabolic pathways as potential biomarker signatures for assessing health, performance, and recovery of elite athletes. Metabolic profiling of serum samples from 495 elite athletes from different sport disciplines (118 high CD and 377 low/moderate CD athletes) was conducted using non-targeted metabolomics-based mass spectroscopy combined with ultra-high-performance liquid chromatography. Results show that DAGs containing arachidonic were enriched in high CD together with branched-chain amino acids, plasminogens, phosphatidylcholines, and phosphatidylethanolamines, potentially indicating increased risk of cardiovascular disease in the high CD group. Gamma-glutamyl amino acids and glutathione metabolism were increased in low/moderate CD group, suggesting more efficient oxidative stress scavenging mechanisms than the high CD group. This first most comprehensive metabolic profiling of elite athletes provides an evidence that athletes with different CD show a unique metabolic signature that reflects energy generation and oxidative stress and potentially places the high CD group at a higher risk of cardiovascular disease. Further studies are warranted for confirmation and validation of findings in other sport groups in light of potential confounders related to limited available information about participants.

Performance of the BMJ learning training modules for ECG interpretation in athletes

To assess the accuracy of interpreting the athlete’s ECG both pre and post a series of online training modules among a range of healthcare professionals. 10 512 healthcare professionals from 138 different nations commenced the online course. These were primarily doctors (43%), nurses (18.4%) and other healthcare professionals (3.9%). The users came from 102 different specialities, with General Practice/Family Medicine (24.5%), Cardiology (10.6%), Emergency Medicine (8.7%) and Sports Medicine (6.6%) predominating. Among the 2023 users who completed both the pre-course and post-course test, there was an overall improvement of 15.3% (95% CI 13.9% to 16.6%; p<0.001). 930 completed all four other modules, and these users fared significantly better (18.7% increase; 95% CI 17.3 to 20.0) than those completing no additional modules (11.7% increase; 95% CI 3.3 to 17.7, p=0.036). Demographic analysis showed that while the starting pre-test scores varied significantly between profession/specialty groups (57.8%–82.6%), post-test scores were largely consistent (80.8%–84.6%). Although users showed the most improvement when interpreting primary electrical diseases (12.4% increase), it was also an area of notable weakness compared with the modules of normal training-related findings and cardiomyopathies. With the evolving criteria for ECG interpretation eliciting ever improving levels of specificity and sensitivity in the detection of conditions associated with sudden cardiac death among athletes, training is required to ensure the infrastructure and personnel is in place to uphold these standards. The BMJ Learning course presented is a valuable first step and demonstrates that such an online tool can be effective in aiding ECG interpretation among healthcare professionals globally.

Coronary artery disease in athletes: An adverse effect of intense exercise?

Regular physical exercise is responsible for various health benefits, and is recommended for primary and secondary cardiovascular (CV) prevention. Despite these recognized benefits, various clinical events can occur in athletes, including acute myocardial infarction and sudden cardiac death (SCD); the main cause of SCD in veteran athletes is coronary artery disease (CAD). The relationship between intense exercise training and CAD is controversial, and a U-shaped association has been hypothesized. If this is the case, screening for subclinical CAD in older athletes may be justified, and various different methodologies have been proposed. However, the methodology for screening veteran athletes is not consensual, and several markers of CAD, in addition to clinical CV risk factors, could improve risk stratification in this population. In the present paper we review the published data on CAD in athletes, focusing on the relationship between the dose of exercise and CAD, as well as the implications for pre-participation screening of veteran athletes.

Moderate Physical Activity in Healthy Adults Is Associated With Cardiac Remodeling

Supplemental Digital Content is available in the text.

Background—

Cardiac mass and volumes are often elevated in athletes, but it is not known whether moderate physical activity is also associated with cardiac dilatation and hypertrophy in a healthy adult population.

Methods and Results—

In total, 1096 adults (54% female, median age 39 years) without cardiovascular disease or cardiomyopathy-associated genetic variants underwent cardiac magnetic resonance imaging to determine biventricular volumes and function. Physical activity was assessed using a validated activity questionnaire. The relationship between cardiac parameters and activity was assessed using multiple linear regression adjusting for age, sex, race, and systolic blood pressure. Logistic regression was performed to determine the effect of activity on the likelihood of subjects having cardiac dilatation or hypertrophy according to standard cardiac magnetic resonance normal ranges. Increasing physical activity was associated with greater left ventricular (LV) mass (β=0.23; P<0.0001) and elevated LV and right ventricular volumes (LV: β=0.26, P<0.0001; right ventricular: β=0.26, P<0.0001). Physical activity had a larger effect on cardiac parameters than systolic blood pressure (0.06≤β≤0.21) and a similar effect to age (−0.20≤β≤−0.31). Increasing physical activity was a risk factor for meeting imaging criteria for LV hypertrophy (adjusted odds ratio 2.1; P<0.0001), LV dilatation (adjusted odds ratio 2.2; P<0.0001), and right ventricular dilatation (adjusted odds ratio 2.2; P<0.0001).

Conclusions—

Exercise-related cardiac remodeling is not confined to athletes, and there is a risk of overdiagnosing cardiac dilatation or hypertrophy in a proportion of active, healthy adults.

Sudden Cardiac Death in Athletes

There are clear health benefits to exercise; even so, patients with cardiac conditions who engage in exercise and athletic competition may on rare occasion experience sudden cardiac death (SCD). This article reviews the epidemiology and common causes of SCD in specific athlete populations. There is ongoing debate about the optimal mechanism for SCD prevention, specifically regarding the inclusion of the ECG and/or cardiac imaging in routine preparticipation sports evaluation. This controversy and contemporary screening recommendations are also reviewed.

Exercise and Arrhythmias: A Double-Edged Sword

Ample evidence indicates that moderate regular exercise is beneficial for both normal individuals and patients with cardiovascular (CV) disease. However, intense and strenuous exercise in individuals with evident or occult underlying CV abnormalities may have adverse effects with provocation and exacerbation of arrhythmias that may lead to life-threatening situations. Both of these aspects of exercise-induced effects are herein reviewed.

Historical Perspectives on Sudden Deaths in Young Athletes With Evolution over 35 Years

Sudden death in young competitive athletes has become a highly visible and substantial issue within cardiovascular medicine of interest both to the general public and to the practicing community. At this time, it is instructive to revisit the evolution of this clinical problem over the past 35 years starting with introduction into the public and medical consciousness by the unexpected sudden deaths of 2 college basketball players within 8 weeks of each other in 1976, 1 with Marfan syndrome and the other with hypertrophic cardiomyopathy. Subsequently, over the next years, a number of elite athletes died suddenly, raising public visibility and awareness of these tragic events: Len Bias, "Pistol" Pete Maravich, Hank Gathers, Reggie Lewis, Kori Stringer, Jason Collier, and Thomas Herrion. Intense interest in these and many other athlete deaths has led to a considerable understanding regarding the demographics, incidence, and causes of these deaths, which include a variety of genetic and/or congenital cardiovascular diseases (most commonly hypertrophic cardiomyopathy), blunt trauma, commotio cordis, and sickle cell trait. Ultimately, initiatives emerged creating consensus guidelines for disqualification versus eligibility decisions, and preparticipation screening to detect unsuspected cardiac abnormalities. This journey of now >3 decades has generated voluminous data and even controversy, but continues to hold great interest in clinical scientists, medical practitioners, and the general public.

The Impact of Sports Cardiology on the Practice of Primary Care Sports Medicine: Where Were We, Where Are We, Where Are We Headed?

This article is a commentary on the role of sports cardiologists in the athletic arena and the beneficial impact they offer sports medicine in the comprehensive care of competitive athletes. The focus is a dialogue on current recommendations for primary prevention of sudden cardiac arrest (SCA), incorporating elements of the preparticipation evaluation and continuing care of athletes with diagnosed heart disease (HD). The feasibility and potential advantages of implementing well-designed preparticipation cardiovascular screening programs and the role of sports cardiologists to educate primary care team physicians on secondary prevention of SCA and proper treatment of underlying HD are discussed.

How to Practice Sports Cardiology: A Cardiology Perspective

The rigorous cardiovascular (CV) demands of sport, combined with training-related cardiac adaptations, render the athlete a truly unique CV patient and sports cardiology a truly unique discipline. Cardiologists are advised to adopt a systematic approach to the CV evaluation of athletes, taking into consideration the individual sports culture, sports-specific CV demands, CV adaptations and their appearance on cardiac testing, any existing or potential interaction of the heart with the internal and external sports environment, short- and long-term CV risks, and potential effect of performance-enhancing agents and antidoping regulations. This article outlines the systematic approach, provides a detailed example, and outlines contemporary sports cardiology core competencies.

Editor-in-Chief's Picks From 2014: Part One

As I spent countless hours pouring over hundreds of manuscripts to select those that rose to the top over the past year, I became incredibly excited about being part of a Journal that produces such wonderfully rich and diverse content each year. I have personally selected the papers (both original investigations and review articles) from 13 distinct specialties for your review. There are approximately 150 articles selected across this 2-part series, which represents less than 3% of the papers submitted to JACC in 2014. In order to present the full breadth of this important research in a consumable fashion, we will present these manuscripts over the course of 2 issues of JACC. Part One includes the sections: Congenital Heart Disease, Coronary Disease & Interventions, Genetics, Omics, & Tissue Regeneration, CV Prevention & Health Promotion, Cardiac Failure, and Cardiomyopathies (1-70). Part Two includes the sections: Hypertension, Imaging, Metabolic Disorders & Lipids, Neurovascular & Neurodegenerative Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine.