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Maron MS, Mitten M, Borchers J, Rowin EJ, Maron BJ. Medical and Legal Determinants of Sports Eligibility for Young Competitive Athletes With Cardiovascular Disease. J Am Coll Cardiol 2023; 82:828-832. [PMID: 37542484 DOI: 10.1016/j.jacc.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Martin S Maron
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA.
| | - Matthew Mitten
- National Sports Law Institute, Marquette University Law School, Milwaukee, Wisconsin, USA
| | - James Borchers
- Division of Family Medicine-Sports Medicine, Ohio State Wexner Medical Center, Columbus, Ohio, USA
| | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA
| | - Barry J Maron
- Hypertrophic Cardiomyopathy Center at Lahey Medical Center and Hospital, Burlington, Massachusetts, USA
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2
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Kim JH. Competitive Sports Participation for Athletes With Genetic Heart Disease: A Whole New Ballgame. J Am Coll Cardiol 2023; 82:671-673. [PMID: 37587577 DOI: 10.1016/j.jacc.2023.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Jonathan H Kim
- Division of Cardiology, Emory Clinical Cardiovascular Research Institute, Atlanta, Georgia, USA.
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Maron MS, Rowin EJ, Bonaventura J, Maron BJ. Do Implantable Cardioverter-Defibrillators Really Belong on the Athlete Field? Am J Cardiol 2023:S0002-9149(23)00343-0. [PMID: 37393157 DOI: 10.1016/j.amjcard.2023.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/10/2023] [Accepted: 05/29/2023] [Indexed: 07/03/2023]
Abstract
High-risk athletes with implanted cardioverter-defibrillators who are competing in intense sports represent a controversial issue in cardiovascular medicine. Such devices have the capability to protect patients with a variety of cardiovascular diseases from sudden death and have aborted potentially lethal events during competitive sports but they can also lead to adverse clinical consequences for athletes with implants and other participants. In conclusion, clinicians and athletes should consider the data presented here in making prudent and informed recommendations regarding the eligibility of this patient group with implanted cardioverter-defibrillators for intense competitive sports.
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Affiliation(s)
- Martin S Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts..
| | - Ethan J Rowin
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Jiri Bonaventura
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Barry J Maron
- HCM Center, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Pollevick ME, Wan EY. Editorial: The role of sex in cardiac arrhythmias and sudden cardiac death. Front Cardiovasc Med 2023; 10:1158376. [PMID: 36937918 PMCID: PMC10021107 DOI: 10.3389/fcvm.2023.1158376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Affiliation(s)
- Matias E. Pollevick
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
| | - Elaine Y. Wan
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States
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Athletic Activity for Patients With Hypertrophic Cardiomyopathy and Other Inherited Cardiovascular Diseases: JACC Focus Seminar 3/4. J Am Coll Cardiol 2022; 80:1268-1283. [PMID: 36075839 DOI: 10.1016/j.jacc.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 02/08/2023]
Abstract
As explored throughout this JACC Focus Seminar series, participation in regular exercise offers significant positive benefits for cardiovascular health. However, patients with underlying inherited cardiovascular diseases, such as hypertrophic cardiomyopathy, have historically been restricted from sports participation because of the risk of sudden cardiac death. Over the last decade, new data has challenged this restrictive approach. Today, the notion of individualized, patient-centered shared decision-making is being progressively adopted to guide patients with an inherited cardiovascular disease to decide if they can undertake regular exercise, or even if they can participate in competitive sports. Here in this part 3 of a 4-part seminar series, we focus on these concepts and recent data with respect to exercise and the heart in patients with hypertrophic cardiomyopathy and other inherited cardiovascular diseases, with particular emphasis on participation in recreational and competitive sports for these individuals.
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Maron BJ, Desai MY, Nishimura RA, Spirito P, Rakowski H, Towbin JA, Rowin EJ, Maron MS, Sherrid MV. Diagnosis and Evaluation of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2022; 79:372-389. [DOI: 10.1016/j.jacc.2021.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 12/20/2022]
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Shapero K, Gier C, Briske K, Spatz ES, Wasfy M, Baggish AL, Pierce S, Ackerman MJ, Lampert R. Experiences of Athletes with Arrhythmogenic Cardiac Conditions in Returning to Play. Heart Rhythm O2 2022; 3:133-140. [PMID: 35496453 PMCID: PMC9043374 DOI: 10.1016/j.hroo.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Recommendations for return to play (RTP) for athletes with genetic (or congenital) heart diseases (GHD) predisposing to sudden cardiac death (SCD) have evolved from an initially paternalistic and conservative approach, to supporting a more flexible approach to decision-making. The experiences of athletes and their families during the RTP process are unknown. Objective To understand current RTP processes. Methods We administered a mixed-methods telephone interview combining quantitative and qualitative components to 30 athletes with a GHD who had RTP, and 23 parents. Participants were identified from the Yale ICD Sports registry and Mayo Clinic’s Windland Smith Rice Genetic Heart Rhythm Clinic. Qualitative data were analyzed using a grounded theory approach to identify common themes. Results Most common diagnoses were long QT syndrome and hypertrophic cardiomyopathy and most common sports, soccer, basketball, and football. Twenty-three athletes encountered ≥1 perceived barrier(s) to RTP: 17 were restricted by their first cardiologist; 6 were required to meet with school administrators, 4 signed waivers, and 3 hired lawyers. Common themes expressed by athletes and their parents were frustration with poor communication, perceived lack of physician knowledge of their diagnosis, and unilateral, paternalistic decision-making, as well as cynicism that physicians and schools were primarily concerned with liability. After RTP, 26 athletes had some form of emergency action plan, although responsibility was often left to the family. Conclusion Many perceived barriers exist for athletes with GHD who wish to RTP after their diagnoses. Shared decision-making from the onset is critical for RTP.
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Heidbuchel H, Adami PE, Antz M, Braunschweig F, Delise P, Scherr D, Solberg EE, Wilhelm M, Pelliccia A. Recommendations for participation in leisure-time physical activity and competitive sports in patients with arrhythmias and potentially arrhythmogenic conditions: Part 1: Supraventricular arrhythmias. A position statement of the Section of Sports Cardiology and Exercise from the European Association of Preventive Cardiology (EAPC) and the European Heart Rhythm Association (EHRA), both associations of the European Society of Cardiology. Eur J Prev Cardiol 2021; 28:1539-1551. [PMID: 32597206 DOI: 10.1177/2047487320925635] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 01/02/2023]
Abstract
Symptoms attributable to arrhythmias are frequently encountered in clinical practice. Cardiologists and sport physicians are required to identify high-risk individuals harbouring such conditions and provide appropriate advice regarding participation in regular exercise programmes and competitive sport. The three aspects that need to be considered are: (a) the risk of life-threatening arrhythmias by participating in sports; (b) control of symptoms due to arrhythmias that are not life-threatening but may hamper performance and/or reduce the quality of life; and (c) the impact of sports on the natural progression of the underlying arrhythmogenic condition. In many cases, there is no unequivocal answer to each aspect and therefore an open discussion with the athlete is necessary, in order to reach a balanced decision. In 2006 the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology published recommendations for participation in leisure-time physical activity and competitive sport in individuals with arrhythmias and potentially arrhythmogenic conditions. More than a decade on, these recommendations are partly obsolete given the evolving knowledge of the diagnosis, management and treatment of these conditions. The present document presents a combined effort by the Sports Cardiology and Exercise Section of the European Association of Preventive Cardiology and the European Heart Rhythm Association to offer a comprehensive overview of the most updated recommendations for practising cardiologists and sport physicians managing athletes with supraventricular arrhythmias, and provides pragmatic advice for safe participation in recreational physical activities, as well as competitive sport at amateur and professional level. A companion text on recommendations in athletes with ventricular arrhythmias, inherited arrhythmogenic conditions, pacemakers and implantable defibrillators is published as Part 2 in Europace.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Belgium
| | - Paolo E Adami
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Germany
| | | | | | - Daniel Scherr
- Department of Medicine, Medical University of Graz, Austria
| | | | | | - Antonio Pelliccia
- Italian National Olympic Committee, Institute of Sport Medicine and Science, Italy
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Drezner JA, Malhotra A, Prutkin JM, Papadakis M, Harmon KG, Asif IM, Owens DS, Marek JC, Sharma S. Return to play with hypertrophic cardiomyopathy: are we moving too fast? A critical review. Br J Sports Med 2021; 55:1041-1047. [PMID: 33472848 PMCID: PMC8408577 DOI: 10.1136/bjsports-2020-102921] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 12/31/2022]
Abstract
The diagnosis of a potentially lethal cardiovascular disease in a young athlete presents a complex dilemma regarding athlete safety, patient autonomy, team or institutional risk tolerance and medical decision-making. Consensus cardiology recommendations previously supported the ‘blanket’ disqualification of athletes with hypertrophic cardiomyopathy (HCM) from competitive sport. More recently, epidemiological studies examining the relative contribution of HCM as a cause of sudden cardiac death (SCD) in young athletes and reports from small cohorts of older athletes with HCM that continue to exercise have fueled debate whether it is safe to play with HCM. Shared decision-making is endorsed within the sports cardiology community in which athletes can make an informed decision about treatment options and potentially elect to continue competitive sports participation. This review critically examines the available evidence relevant to sports eligibility decisions in young athletes diagnosed with HCM. Histopathologically, HCM presents an unstable myocardial substrate that is vulnerable to ventricular tachyarrhythmias during exercise. Studies support that young age and intense competitive sports are risk factors for SCD in patients with HCM. We provide an estimate of annual mortality based on our understanding of disease prevalence and the incidence of HCM-related SCD in different athlete populations. Adolescent and young adult male athletes and athletes participating in a higher risk sport such as basketball, soccer and American football exhibit a greater risk. This review explores the potential harms and benefits of sports disqualification in athletes with HCM and details the challenges and limitations of shared decision-making when all parties may not agree.
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Affiliation(s)
- Jonathan A Drezner
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Aneil Malhotra
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Jordan M Prutkin
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Michael Papadakis
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
| | - Kimberly G Harmon
- Center for Sports Cardiology, University of Washington, Seattle, Washington, USA
| | - Irfan M Asif
- Center for Health Promotion, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David S Owens
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Joseph C Marek
- Cardiology, Advocate Heart Institute, Downers Grove, Illinois, USA
| | - Sanjay Sharma
- Cardiology, Clinical Academic Group, St George's, University of London, London, UK
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Sport Participation in Patients with Implantable Cardioverter-Defibrillators. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:66. [PMID: 31728782 DOI: 10.1007/s11936-019-0772-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW Athletes diagnosed with cardiovascular disease may receive implantable cardioverter defibrillators (ICDs). Until recently, there were no data describing the safety of return to play for athletes receiving an ICD, and consensus recommendations restricted ICD patients to competitive sports no more vigorous than bowling or golf. RECENT FINDINGS The ICD Sports Registry prospectively followed 440 athletes who continued sports participation after receiving an ICD, for up to 4 years. While many received shocks, both appropriate and inappropriate, during competition or practice, as well as during other physical activity or rest, there were no failures to defibrillate and no injuries related to arrhythmia or shock during sports. Recent subanalyses as described below have focused on how best to program the ICD, and on the younger subgroup including interscholastic athletes. Based on these data, the most recent consensus statement from the AHA/ACC on athletic eligibility now describes sports participation with an ICD as a IIB recommendation, "may be considered".
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Johri AM, Poirier P, Dorian P, Fournier A, Goodman JM, McKinney J, Moulson N, Pipe A, Philippon F, Taylor T, Connelly K, Baggish AL, Krahn A, Sharma S. Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes. Can J Cardiol 2019; 35:1-11. [DOI: 10.1016/j.cjca.2018.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022] Open
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Providencia R, Teixeira C, Segal OR, Ullstein A, Mueser K, Lambiase PD. Empowerment of athletes with cardiac disorders: a new paradigm. Europace 2018; 20:1243-1251. [PMID: 29016796 PMCID: PMC6075459 DOI: 10.1093/europace/eux268] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 07/14/2017] [Indexed: 12/11/2022] Open
Abstract
Athletes with cardiac disorders frequently pose an ethical and medical dilemma to physicians assessing their eligibility to participate in sport. In recent decades, patient empowerment has been gaining increasing recognition in clinical decision-making. Empowerment is a process through which people are involved over the decisions and actions that affect their own lives. In the context of a cardiac disorder, empowerment means giving an athlete the chance to participate in the decision about whether or not to remain active in competition. Three models of treatment decision-making are described in this article, with progressive levels of empowerment: the paternalistic model (the athlete has a passive role), the shared-decision making model (both athlete and physician participate in the decision), and the informed-decision making (the decision is made by the athlete while the role of the physician is solely to provide information). This article critically discusses the issues involved in disqualification of athletes with cardiovascular disorders and suggests possible ways of incorporating patient empowerment in potentially career-ending decisions. The authors propose a model of empowerment, which gives patients the opportunity to choose how much, and if, they would like to be involved in the decision-making process.
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Affiliation(s)
- Rui Providencia
- Farr Institute of Health Informatics, University College London, London, UK
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Carina Teixeira
- Centre for Psychiatric Rehabilitation, Boston University, Boston, MA, USA
| | - Oliver R Segal
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | | | - Kim Mueser
- Centre for Psychiatric Rehabilitation, Boston University, Boston, MA, USA
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- Institute of Cardiovascular Science, University College of London, London, UK
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Providencia R, Teixeira C, Segal OR, Ullstein A, Lambiase PD. Call for joint informed consent in athletes with inherited cardiac conditions. Open Heart 2017; 4:e000516. [PMID: 28890793 PMCID: PMC5566987 DOI: 10.1136/openhrt-2016-000516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/17/2016] [Accepted: 09/21/2016] [Indexed: 01/02/2023] Open
Abstract
Informed consent is of the utmost importance, especially in complex clinical situations where patients may be exposed to a life-threatening risk. A particularly complex example is the eligibility of competitive athletes with inherited cardiac conditions on medical grounds, especially when the risk is low or unquantifiable. The rationale and benefits of a joint informed consent for athletes to compete with potentially life-threatening cardiac conditions are discussed in this manuscript.
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Affiliation(s)
| | - Carina Teixeira
- Centre for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts, USA
| | | | | | - Pier D Lambiase
- Barts Health NHS Trust, London, UK.,University College of London, London, UK
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Abstract
Improved public awareness and advances in medical diagnostics have resulted in the development of criteria to determine eligibility or disqualification for the athlete with cardiovascular abnormalities. Simultaneously, protocols have been developed for athletes with concussion or orthopaedic injuries to guide team physicians and consultants in return-to-play decisions. However, there are currently inadequate data to allow the development of such protocols for athletes with cardiovascular abnormalities who have undergone treatment. Further complicating the decision process is the designation of the team physician as the ultimate authority in making return-to-play decisions - where the team physician often is an employee of the team and supports the team's goal and players as well as the individual athlete. This review will discuss the ethical dilemma of the team physician and the role of the cardiovascular consultant. Following this, current data and practices regarding return to play will be discussed for the following conditions or diagnoses: following catheter ablation for supraventricular tachycardia; following pacemaker or implantable cardioverter-defibrillator implantation; unexplained syncope; and the athlete with a genetic mutation in the absence of any phenotype of associated disease. These recommendations will undoubtedly continue to evolve and improve and should be considered at this time as a point of departure.
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Abstract
Physicians participate in the screening, routine medical supervision, and disqualification of student-athletes. In doing so, they should understand that eligibility/disqualification decisions inevitably have associated liability issues. It is the responsibility of physicians to take the lead role in the student-athlete medical assessment process to allow for optimum safety in sports programmes. The first duty of the physician is to protect the health and well-being of the student-athlete. However, because there is potential liability associated with the screening/disqualification process, physicians are wise to develop sound and reasonable strategies that are in strict compliance with the standard of care. This article focusses on cardiac screening and disqualification for participation in sports.
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Sweeting J, Ingles J, Ball K, Semsarian C. Challenges of exercise recommendations and sports participation in genetic heart disease patients. ACTA ACUST UNITED AC 2015; 8:178-86. [PMID: 25691687 DOI: 10.1161/circgenetics.114.000784] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Joanna Sweeting
- From the Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, NSW, Australia (J.S., J.I., C.S.); Sydney Medical School, University of Sydney, Sydney, NSW, Australia (J.S., J.I., C.S.); Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia (K.B.); and Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.S.)
| | - Jodie Ingles
- From the Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, NSW, Australia (J.S., J.I., C.S.); Sydney Medical School, University of Sydney, Sydney, NSW, Australia (J.S., J.I., C.S.); Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia (K.B.); and Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.S.)
| | - Kylie Ball
- From the Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, NSW, Australia (J.S., J.I., C.S.); Sydney Medical School, University of Sydney, Sydney, NSW, Australia (J.S., J.I., C.S.); Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia (K.B.); and Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.S.)
| | - Christopher Semsarian
- From the Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Newtown, NSW, Australia (J.S., J.I., C.S.); Sydney Medical School, University of Sydney, Sydney, NSW, Australia (J.S., J.I., C.S.); Centre for Physical Activity and Nutrition Research, Deakin University, Melbourne, Australia (K.B.); and Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia (C.S.).
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Mitten MJ, Zipes DP, Maron BJ, Bryant WJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations. J Am Coll Cardiol 2015; 66:2447-2450. [DOI: 10.1016/j.jacc.2015.09.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mitten MJ, Zipes DP, Maron BJ, Bryant WJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e346-9. [PMID: 26621654 DOI: 10.1161/cir.0000000000000251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Maron BJ, Zipes DP, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2015; 132:e256-61. [PMID: 26621642 DOI: 10.1161/cir.0000000000000236] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Maron BJ, Zipes DP, Kovacs RJ. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Preamble, Principles, and General Considerations: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2343-2349. [PMID: 26542655 DOI: 10.1016/j.jacc.2015.09.032] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Maron BJ. Historical Perspectives on Sudden Deaths in Young Athletes With Evolution over 35 Years. Am J Cardiol 2015; 116:1461-8. [PMID: 26394831 DOI: 10.1016/j.amjcard.2015.07.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/24/2015] [Accepted: 07/24/2015] [Indexed: 01/02/2023]
Abstract
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.
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Conley KM, Bolin DJ, Carek PJ, Konin JG, Neal TL, Violette D. National Athletic Trainers' Association position statement: Preparticipation physical examinations and disqualifying conditions. J Athl Train 2015; 49:102-20. [PMID: 24499039 DOI: 10.4085/1062-6050-48.6.05] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To present athletic trainers with recommendations for the content and administration of the preparticipation physical examination (PPE) as well as considerations for determining safe participation in sports and identifying disqualifying conditions. BACKGROUND Preparticipation physical examinations have been used routinely for nearly 40 years. However, considerable debate exists as to their efficacy due to the lack of standardization in the process and the lack of conformity in the information that is gathered. With the continuing rise in sports participation at all levels and the growing number of reported cases of sudden death in organized athletics, the sports medicine community should consider adopting a standardized process for conducting the PPE to protect all parties. RECOMMENDATIONS Recommendations are provided to equip the sports medicine community with the tools necessary to conduct the PPE as effectively and efficiently as possible using available scientific evidence and best practices. In addition, the recommendations will help clinicians identify those conditions that may threaten the health and safety of participants in organized sports, may require further evaluation and intervention, or may result in potential disqualification.
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Alpert C, Day SM, Saberi S. Sports and Exercise in Athletes with Hypertrophic Cardiomyopathy. Clin Sports Med 2015; 34:489-505. [DOI: 10.1016/j.csm.2015.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Vetter VL. Electrocardiographic screening of all infants, children, and teenagers should be performed. Circulation 2015; 130:688-97; discussion 697. [PMID: 25135125 DOI: 10.1161/circulationaha.114.009737] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Victoria L Vetter
- From The Children's Hospital of Philadelphia, and Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.
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Maron BJ, Friedman RA, Kligfield P, Levine BD, Viskin S, Chaitman BR, Okin PM, Saul JP, Salberg L, Van Hare GF, Soliman EZ, Chen J, Matherne GP, Bolling SF, Mitten MJ, Caplan A, Balady GJ, Thompson PD. Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age). Circulation 2014; 130:1303-34. [DOI: 10.1161/cir.0000000000000025] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Maron BJ, Friedman RA, Kligfield P, Levine BD, Viskin S, Chaitman BR, Okin PM, Saul JP, Salberg L, Van Hare GF, Soliman EZ, Chen J, Matherne GP, Bolling SF, Mitten MJ, Caplan A, Balady GJ, Thompson PD. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 2014; 64:1479-514. [PMID: 25234655 DOI: 10.1016/j.jacc.2014.05.006] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Panhuyzen-Goedkoop NM, Smeets JLRM. Legal responsibilities of physicians when making participation decisions in athletes with cardiac disorders: Do guidelines provide a solid legal footing? Br J Sports Med 2014; 48:1193-5. [DOI: 10.1136/bjsports-2013-093023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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29
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Pelliccia A. Long QT syndrome, implantable cardioverter defibrillator (ICD) and competitive sport participation: when science overcomes ethics. Br J Sports Med 2013; 48:1135-6. [DOI: 10.1136/bjsports-2013-092441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
Sport activity is an important issue in many patients with a pacemaker either because they performed sport activities before pacemaker implantation to reduce the cardiovascular risk or to improve the course of an underlying cardiovascular disease (e.g. coronary artery disease, heart failure) by sports. Compared to patients with an implantable cardioverter defibrillator (ICD) the risks from underlying cardiovascular disease (e.g. ischemia, heart failure), arrhythmia, lead dysfunction or inappropriate therapy are less important or absent. Sport is contraindicated in dyspnea at rest, acute heart failure, new complex arrhythmia, acute myocarditis and acute myocardial infarction, valvular disease with indications for intervention and surgery and comorbidities which prevent physical activity. Patients with underlying cardiovascular disease (including hypertension) should preferably perform types and levels of physical activity that are aerobic (with dynamic exercise) such as running, swimming, cycling instead of sport with high anaerobic demands and high muscular workload. In heart failure, studies demonstrated advantages of isometric sport that increases the amount of muscle, thereby preventing cardiac cachexia. Sport with a risk of blows to the chest or physical contact (e.g. boxing, rugby, martial arts) should be avoided. Implantation, programming and follow-up should respect specific precautions to allow optimal physical activity with a pacemaker including implantation of bipolar leads on the side contralateral to the dominant hand, individual programming of the upper sensor and tracking rate and regular exercise testing.
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31
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Maron BJ. Counterpoint: Mandatory ECG screening of young competitive athletes. Heart Rhythm 2012; 9:1646-9. [DOI: 10.1016/j.hrthm.2012.03.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Indexed: 12/22/2022]
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Affiliation(s)
- Eric F Quandt
- Pugh, Jones, Johnson & Quandt, PC, Chicago, Illinois
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Morse E, Funk M. Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care. ACTA ACUST UNITED AC 2012; 24:63-9. [DOI: 10.1111/j.1745-7599.2011.00694.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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Patel A, Lantos JD. Can we prevent sudden cardiac death in young athletes: the debate about preparticipation sports screening. Acta Paediatr 2011; 100:1297-301. [PMID: 21535127 DOI: 10.1111/j.1651-2227.2011.02337.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
UNLABELLED All high school athletes in the United States require a preparticipation screening examination. The American Heart Association recommends a focused history and physical examination. The European Society of Cardiology recommends that all examinations include an electrocardiogram (ECG). We review the risks and costs of screening, discuss legal ramifications and analyse the ethical implications of these considerations. There are too many unknown about ECG screening to require it as routine testing for all high school athletes. CONCLUSION Doctors must inform young athletes and their parents about the option of ECG screening and about the debate over its efficacy. Patients and parents may then choose to have an ECG or not. Mandatory universal screening is not warranted at this time.
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Affiliation(s)
- Angira Patel
- Division of Cardiology, Children's Memorial Hospital, Chicago, IL 64108, USA
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Varró A, Baczkó I. Possible mechanisms of sudden cardiac death in top athletes: a basic cardiac electrophysiological point of view. Pflugers Arch 2010; 460:31-40. [PMID: 20186549 DOI: 10.1007/s00424-010-0798-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 02/01/2010] [Accepted: 02/03/2010] [Indexed: 10/19/2022]
Abstract
Sudden death among athletes is very rare (1:50,000-1:100,000 annually) but it is still 2-4 times more frequent than in the age-matched control population and attracts significant media attention. We propose a mechanism underlying sudden cardiac death in athletes that does not relate to myocardial ischemia but is based on repolarization abnormalities due to potassium channel downregulation and can also be best explained by the concurrent presence of several factors such as cardiac hypertrophy (athlete's heart), and/or hypertrophic cardiomyopathy, increased sympathetic tone, genetic defects, drugs, doping agents, food, or dietary ingredients. These factors together can increase the repolarization inhomogeneity of the heart ("substrate") and an otherwise harmless extrasystole ("trigger") occurring with a very unfortunate timing may sometimes induce life-threatening arrhythmias. The effective and possible prevention of sudden cardiac death requires the development of novel cost effective cardiac electrophysiological screening methods. Athletes identified by these tests as individuals at higher proarrhythmic risk should then be subjected to more costly genetic tests in order to uncover possible underlying genetic causes for alterations in ionic channel structure and/or function.
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Affiliation(s)
- András Varró
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, Dóm tér 12, 6720, Szeged, Hungary.
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Contemporary management of vascular complications associated with Ehlers-Danlos syndrome. J Vasc Surg 2009; 51:131-8; discussion 138-9. [PMID: 19879095 DOI: 10.1016/j.jvs.2009.08.019] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/04/2009] [Accepted: 08/04/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVES There has been debate regarding the safety of performing elective procedures in patients with vascular manifestations associated with Ehlers-Danlos syndrome (EDS). The purpose of this study was to review the surgical management and clinical outcomes of EDS patients undergoing vascular procedures at a tertiary medical center with multimodality expertise in connective tissue disorders. METHODS All patients with EDS undergoing endovascular and open vascular procedures at a single-institution academic medical center from 1994 to 2009 were retrospectively reviewed. Clinical data were evaluated including patient demographics, length of stay (LOS), and mortality outcomes during hospital course and long-term follow-up. RESULTS A total of 40 patients with EDS were identified, including individuals diagnosed with classic (n = 15), hypermobility (n = 16), and vascular (n = 9) types of EDS. These patients collectively underwent 45 endovascular and 18 open procedures for vascular disease during the time period, including embolization (n = 37), angioplasty (n = 8), arterial bypass (n = 5), and aortic aneurysm repair (n = 13). All cases were performed electively, except for one (2%) urgent endovascular and one (5%) emergent open procedure. Endovascular procedures were associated with a median LOS (interquartile range [IQR]) of 2 (1 to 3) days with no procedure-related mortality or in-hospital deaths among all EDS types, whereas open vascular procedures had median LOS (IQR) of 6 (5 to 8) days with one (6%) in-hospital death occurring in a vascular EDS patient. Survival free of any complication at 5 years was 85% and 54% following endovascular and open procedures, respectively. CONCLUSIONS The elective surgical management of vascular disorders in EDS patients using open and endovascular procedures has been associated with good outcomes. Our results suggest that vascular interventions in these EDS patients can be safely performed and should not be withheld until rupture or acute symptoms arise.
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Jayachandran JV. Searching for triggers of sudden death in hypertrophic cardiomyopathy: Chasing after the wind? Heart Rhythm 2009; 6:603-4. [DOI: 10.1016/j.hrthm.2009.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2009] [Indexed: 10/21/2022]
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Abstract
Many sets of guidelines written by experts in their fields can assist sports medicine physicians to make return-to-play decisions for athletes with known or suspected cardiac conditions. These guidelines can be divided into pre-participation screening guidelines, such as the 2007 American Heart Association (AHA) 12-element screening examination, and specific recommendations for those with heart disease or symptoms. Several important documents fall into the latter category. Among these are the 36th Bethesda Guidelines, the European Society of Cardiology Guidelines, the AHA Consensus Document for Young People with Genetic Conditions, the Heart Rhythm Society Guidelines, and the Guidelines for Masters Athletes. Guidelines are designed to enhance the sports medicine physician's probability of detecting heart disease and making wise participation and return-to-play decisions in athletes with high-risk cardiac conditions, such as hypertrophic cardiomyopathy, anomalous coronary artery, myocarditis, and valvular heart disease. Guidelines also aid in writing exercise prescriptions for those deemed too high risk for sports participation. Because the guidelines may not be entirely consistent on all topics, or based on opinion rather than research evidence, many cases require additional input from a cardiologist or electrophysiologist. Guidelines address not only specific disease entities, but also how corrective surgery, ablations, implantable defibrillators, or drug therapy can influence return-to-play decisions. They are updated as new studies become available to provide physicians with the most up-to-date information.
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Pelliccia A, Zipes DP, Maron BJ. Bethesda Conference #36 and the European Society of Cardiology Consensus Recommendations Revisited. J Am Coll Cardiol 2008; 52:1990-6. [PMID: 19055990 DOI: 10.1016/j.jacc.2008.08.055] [Citation(s) in RCA: 216] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 08/08/2008] [Accepted: 08/11/2008] [Indexed: 01/02/2023]
Affiliation(s)
- Antonio Pelliccia
- Institute of Sports Medicine and Science, Italian National Olympic Committee, Rome, Italy.
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41
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It is not prudent to allow all athletes with implantable-cardioverter defibrillators to participate in all sports. Heart Rhythm 2008; 5:864-6. [DOI: 10.1016/j.hrthm.2008.01.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 01/19/2008] [Indexed: 11/21/2022]
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Myerburg RJ, Vetter VL. Electrocardiograms should be included in preparticipation screening of athletes. Circulation 2008; 116:2616-26; discussion 2626. [PMID: 18040041 DOI: 10.1161/circulationaha.107.733519] [Citation(s) in RCA: 147] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Robert J Myerburg
- Division of Cardiology (D-39), University of Miami Miller School of Medicine, PO Box 016960, Miami, FL 33101, USA.
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Maron BJ. Hypertrophic cardiomyopathy and other causes of sudden cardiac death in young competitive athletes, with considerations for preparticipation screening and criteria for disqualification. Cardiol Clin 2008; 25:399-414, vi. [PMID: 17961794 DOI: 10.1016/j.ccl.2007.07.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Cardiovascular disease is the most frequent cause of death in young athletes, and hypertrophic cardiomyopathy (HCM) is the single most common condition responsible for these tragedies. Detection of diseases such as HCM can be achieved in general athlete populations through preparticipation screening, and most effectively if testing with electrocardiography or echocardiography is incorporated into the process. Criteria for disqualification and eligibility, based on identified cardiovascular abnormalities, are available in consensus panel guidelines for both United States and European athletes. Removal from intense training and competition is recommended for athletes with HCM, some of whom may ultimately be judged to be at unacceptably high risk for sudden death and eligible for prophylactic defibrillator implantation.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN 55407, USA.
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46
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Maron BJ, Roberts WC. Barry Joel Maron, MD: a conversation with the Editor. Interview by William Clifford Roberts. Am J Cardiol 2007; 99:1334-49. [PMID: 17478169 DOI: 10.1016/j.amjcard.2007.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 02/07/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Barry Joel Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota 55407, USA
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48
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Coronary Anomalies. Curr Sports Med Rep 2007. [DOI: 10.1097/01.csmr.0000306447.71573.fe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rommel M, Griffin R, Harrison EE. Coronary anomalies: Cardiac CT evaluation of the symptomatic adult athlete. Curr Sports Med Rep 2007; 6:85-92. [PMID: 17376336 DOI: 10.1007/bf02941148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Cardiac CT has become widely available as a diagnostic test. It is noninvasive, low risk (for contrast allergies), quick, and highly sensitive for identifying the coronary origins and course. Two coronary anomalies, the left main artery from the right sinus of Valsalva, and the right coronary artery originating from the left sinus, have been associated both with myocardial ischemia and sudden cardiac death when they course between the aorta and pulmonary arteries. These anomalies can go undetected into adulthood. The yield of noninvasive exercise testing is low. In the past, the ability to demonstrate these anomalies depended on a high index of suspicion and an aggressive invasive work-up with cardiac catheterization. Now cardiac CT can demonstrate these anomalies with ease and facilitate appropriate treatment.
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Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D, Dimeff R, Douglas PS, Glover DW, Hutter AM, Krauss MD, Maron MS, Mitten MJ, Roberts WO, Puffer JC. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007; 115:1643-455. [PMID: 17353433 DOI: 10.1161/circulationaha.107.181423] [Citation(s) in RCA: 612] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
MESH Headings
- Adolescent
- Adult
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/diagnostic imaging
- Cardiomyopathy, Hypertrophic/epidemiology
- Cardiovascular Diseases/diagnosis
- Cardiovascular Diseases/diagnostic imaging
- Cardiovascular Diseases/epidemiology
- Cardiovascular Diseases/prevention & control
- Child
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/prevention & control
- Echocardiography/economics
- Echocardiography/statistics & numerical data
- Electrocardiography/economics
- Electrocardiography/statistics & numerical data
- Europe
- Female
- Guideline Adherence/legislation & jurisprudence
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/epidemiology
- Humans
- Male
- Mass Screening/economics
- Mass Screening/ethics
- Mass Screening/legislation & jurisprudence
- Mass Screening/standards
- Physical Exertion
- Prevalence
- Sports
- Sports Medicine/ethics
- Sports Medicine/legislation & jurisprudence
- Sports Medicine/standards
- United States/epidemiology
- Volunteers
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