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Henning RJ. The differentiation of the competitive athlete with physiologic cardiac remodeling from the athlete with cardiomyopathy. Curr Probl Cardiol 2024; 49:102473. [PMID: 38447749 DOI: 10.1016/j.cpcardiol.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 03/08/2024]
Abstract
There are currently 5 million active high school, collegiate, professional, and master athletes in the United States. Regular intense exercise by these athletes can promote structural, electrical and functional remodeling of the heart, which is termed the "athlete's heart." In addition, regular intense exercise can lead to pathological adaptions that promote or worsen cardiac disease. Many of the athletes in the United States seek medical care. Consequently, physicians must be aware of the normal cardiac anatomy and physiology of the athlete, the differentiation of the normal athlete heart from the athlete with cardiomyopathy, and the contemporary care of the athlete with a cardiomyopathy. In athletes with persistent cardiovascular symptoms, investigations should include a detailed history and physical examination, an ECG, a transthoracic echocardiogram, and in athletes in whom the diagnosis is uncertain, a maximal exercise stress test or a continuous ECG recording, and cardiac magnetic resonance imaging or cardiac computed tomography angiography when definition of the coronary anatomy or characterization of the aorta and the aortic great vessels is indicated. This article discusses the differentiation of the normal athlete with physiologic cardiac remodeling from the athlete with hypertrophic, dilated or arrhythmogenic ventricular cardiomyopathy (ACM). The ECG changes in trained athletes that are considered normal, borderline, or abnormal are listed. In addition, the normal echocardiographic measurements for athletes who consistently participate in endurance, power, combined or heterogeneous sports are enumerated and discussed. Algorithms are listed that are useful in the diagnosis of trained athletes with borderline or abnormal echocardiographic measurements suggestive of cardiomyopathies along with the major and minor criteria for the diagnosis of ACM in athletes. Thereafter, the treatment of athletes with hypertrophic, dilated, and arrhythmogenic right ventricular cardiomyopathies are reviewed. The distinction between physiologic changes and pathologic changes in the hearts of athletes has important therapeutic and prognostic implications. Failure by the physician to correctly diagnose an athlete with hypertrophic cardiomyopathy, dilated cardiomyopathy, or ACM, can lead to the sudden cardiac arrest and death of the athlete during training or sports competition. Conversely, an incorrect diagnosis by a physician of cardiac pathology in a normal athlete can lead to an unnecessary restriction of athlete training and competition with resultant significant emotional, psychological, financial, and long-term health consequences in the athlete.
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Yamagata LM, Yamagata K, Borg A, Abela M. Shifting paradigms in hypertrophic cardiomyopathy: the role of exercise in disease management. Hellenic J Cardiol 2024:S1109-9666(24)00138-6. [PMID: 38977062 DOI: 10.1016/j.hjc.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/29/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is traditionally associated with exercise restriction due to potential risks, yet recent evidence and guidelines suggest a more permissive stance for low-risk individuals. The aim of this comprehensive review was to examine existing research on the impact of exercise on cardiovascular outcomes, safety, and quality of life in this population and to consider implications for clinical practice. Recent studies suggest that regular exercise and physical activity in low-risk individuals with HCM are associated with positive outcomes in functional capacity, haemodynamic response, and quality of life, with consistent safety. Various studies highlight the safety of moderate-intensity exercise, showing improvements in exercise capacity without adverse cardiac remodelling or significant arrhythmias. Psychological benefits, including reductions in anxiety and depression, have been also reported following structured exercise programmes. These findings support the potential benefits of integrating individualised exercise regimens in the management of low-risk individuals with HCM, with the aim of improving their overall well-being and cardiovascular health. Adoption of the FITT (frequency, intensity, time, and type of exercise) principle, consideration of individual risk profiles, and shared decision-making are recommended. Future research is warranted to clarify the definition of 'low risk' for exercise participation and investigate the influence of physical activity on disease progression in HCM. Innovation in therapeutic strategies and lifestyle interventions, alongside improved patient and provider education, will help advance the care and safety of individuals with HCM engaging in exercise.
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Affiliation(s)
| | - Kentaro Yamagata
- Department of Cardiology, Mater Dei Hospital, Msida, Malta; Institute of Sport, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Alexander Borg
- Department of Cardiology, Mater Dei Hospital, Msida, Malta
| | - Mark Abela
- Department of Cardiology, Mater Dei Hospital, Msida, Malta; Cardiovascular and Genomics Research Institute at St George's, University of London, London, United Kingdom
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3
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Kay B, Lampert R. Devices and Athletics: Decision-Making Around Return to Play. Card Electrophysiol Clin 2024; 16:81-92. [PMID: 38280816 DOI: 10.1016/j.ccep.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Until recently, implantable cardioverter defibrillators (ICDs) were considered a contraindication to competitive athletics. Recent prospective observational registry data in athletes with ICDs who participated in sports against the societal recommendations at the time have demonstrated the safety of sports participation. While athletes did receive both appropriate and inappropriate shocks, these were not more frequent during sports participation than other activity, and there were no sports-related deaths or need for external resuscitation in the 440 athlete cohort (median followup 44 months). Optimization of medical therapies, device settings and having an emergency action plan allow many athletes to safely continue athletic activity.
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Affiliation(s)
- Bradley Kay
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, Dana 319, New Haven, CT 06520, USA
| | - Rachel Lampert
- Section of Cardiovascular Medicine, Yale School of Medicine, 789 Howard Avenue, Dana 319, New Haven, CT 06520, USA.
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4
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Arbelo E, Protonotarios A, Gimeno JR, Arbustini E, Barriales-Villa R, Basso C, Bezzina CR, Biagini E, Blom NA, de Boer RA, De Winter T, Elliott PM, Flather M, Garcia-Pavia P, Haugaa KH, Ingles J, Jurcut RO, Klaassen S, Limongelli G, Loeys B, Mogensen J, Olivotto I, Pantazis A, Sharma S, Van Tintelen JP, Ware JS, Kaski JP. 2023 ESC Guidelines for the management of cardiomyopathies. Eur Heart J 2023; 44:3503-3626. [PMID: 37622657 DOI: 10.1093/eurheartj/ehad194] [Citation(s) in RCA: 300] [Impact Index Per Article: 300.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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5
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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: 1] [Impact Index Per Article: 1.0] [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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6
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Moulson N, Petek BJ, Ackerman MJ, Churchill TW, Day SM, Kim JH, Kliethermes SA, Lampert R, Levine BD, Martinez MW, Patel MR, Phelan D, Harmon KG, Baggish AL, Drezner JA. Rationale and Design of the ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) Study. J Am Heart Assoc 2023; 12:e029052. [PMID: 37259981 PMCID: PMC10382007 DOI: 10.1161/jaha.122.029052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/13/2023] [Indexed: 06/02/2023]
Abstract
Background Clinical practice recommendations for participation in sports and exercise among young competitive athletes with cardiovascular conditions at risk for sudden death are based largely on expert consensus with a paucity of prospective outcomes data. Recent guidelines have taken a more permissive approach, using a shared decision-making model. However, the impact and outcomes of this strategy remain unknown. Methods The ORCCA (Outcomes Registry for Cardiac Conditions in Athletes) study is a prospective, multicenter, longitudinal, observational cohort study designed to monitor clinical outcomes in athletes with potentially life-threatening cardiovascular conditions. The study will assess sports eligibility decision-making, exercise habits, psychosocial well-being, and long-term cardiovascular outcomes among young competitive athletes with cardiovascular conditions. Competitive athletes aged 18 to <35 years diagnosed with a confirmed cardiovascular condition or borderline finding with potential increased risk of major adverse cardiovascular events are eligible. Outcomes will be monitored for an initial 5-year follow-up period or until age 35, and metrics of psychosocial well-being and composite adverse cardiovascular events including arrhythmias, sudden cardiac arrest/sudden cardiac death, and evidence of disease progression will be compared among athletes who continue versus discontinue competitive sports participation. Conclusions The ORCCA study aims to assess the process and results of return to sport decision-making and to monitor major adverse cardiovascular events, exercise habits, and the psychosocial well-being among young competitive athletes diagnosed with confirmed cardiovascular conditions or borderline findings with potential increased risk of major adverse cardiovascular events. The results of this work will generate an evidence base to inform future guidelines.
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Affiliation(s)
- Nathaniel Moulson
- Division of Cardiology and Sports Cardiology BCUniversity of British ColumbiaVancouverBCUSA
| | - Bradley J. Petek
- Massachusetts General Hospital Division of CardiologyBostonMAUSA
- Cardiovascular Performance ProgramBostonMAUSA
| | - Michael J. Ackerman
- Departments of Cardiovascular Medicine, Pediatric and Adolescent Medicine, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric CardiologyWindland Smith Rice Genetic Heart Rhythm Clinic and Windland Smith Rice Sudden Death Genomics LaboratoryRochesterMNUSA
| | - Timothy W. Churchill
- Massachusetts General Hospital Division of CardiologyBostonMAUSA
- Cardiovascular Performance ProgramBostonMAUSA
| | - Sharlene M. Day
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Jonathan H. Kim
- Division of CardiologyEmory University School of MedicineAtlantaGAUSA
| | | | - Rachel Lampert
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of MedicineNew HavenCTUSA
| | - Benjamin D. Levine
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Matthew W. Martinez
- Department of Cardiovascular Medicine, Morristown Medical Center, Atlantic Health SystemMorristownNJUSA
| | - Manesh R. Patel
- Division of CardiologyDuke Heart Center, and Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | - Dermot Phelan
- Sports Cardiology CenterAtrium Health Sanger Heart & Vascular InstituteCharlotteNCUSA
| | - Kimberly G. Harmon
- Department of Family Medicine and Center for Sports CardiologyUniversity of WashingtonSeattleWAUSA
| | - Aaron L. Baggish
- Department of CardiologyLausanne University Hospital (CHUV)LausanneSwitzerland
- Institute for Sport Science, University of Lausanne (ISSUL)LausanneSwitzerland
| | - Jonathan A. Drezner
- Department of Family Medicine and Center for Sports CardiologyUniversity of WashingtonSeattleWAUSA
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Kaski JP, Kammeraad JAE, Blom NA, Happonen JM, Janousek J, Klaassen S, Limongelli G, Östman-Smith I, Sarquella Brugada G, Ziolkowska L. Indications and management of implantable cardioverter-defibrillator therapy in childhood hypertrophic cardiomyopathy. Cardiol Young 2023; 33:681-698. [PMID: 37102324 DOI: 10.1017/s1047951123000872] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Sudden cardiac death is the most common mode of death during childhood and adolescence in hypertrophic cardiomyopathy, and identifying those individuals at highest risk is a major aspect of clinical care. The mainstay of preventative therapy is the implantable cardioverter-defibrillator, which has been shown to be effective at terminating malignant ventricular arrhythmias in children with hypertrophic cardiomyopathy but can be associated with substantial morbidity. Accurate identification of those children at highest risk who would benefit most from implantable cardioverter-defibrillator implantation while minimising the risk of complications is, therefore, essential. This position statement, on behalf of the Association for European Paediatric and Congenital Cardiology (AEPC), reviews the currently available data on established and proposed risk factors for sudden cardiac death in childhood-onset hypertrophic cardiomyopathy and current approaches for risk stratification in this population. It also provides guidance on identification of individuals at risk of sudden cardiac death and optimal management of implantable cardioverter-defibrillators in children and adolescents with hypertrophic cardiomyopathy.
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Affiliation(s)
- Juan Pablo Kaski
- Centre for Paediatric Inherited and Rare Cardiovascular Disease, University College London Institute of Cardiovascular Science, London, UK
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, UK
| | - Janneke A E Kammeraad
- Erasmus MC - Sophia Children's Hospital, Department of Paediatric Cardiology, Rotterdam, the Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, University of Leiden, Leiden, the Netherlands
- Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Juha-Matti Happonen
- Department of Paediatric Cardiology, Helsinki University Children's Hospital, Helsinki, Finland
| | - Jan Janousek
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Sabine Klaassen
- Department of Pediatric Cardiology, Charite-Universitatsmedizin Berlin, Berlin, Germany
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, AO dei Colli Monaldi Hospital, Universita della Campania "Luigi Vanvitelli", Naples, Italy
| | - Ingegerd Östman-Smith
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Pelliccia A, Day S, Olivotto I. Leisure-time and competitive sport participation: a changing paradigm for HCM patients. Eur J Prev Cardiol 2023; 30:zwad011. [PMID: 36638119 DOI: 10.1093/eurjpc/zwad011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 12/12/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023]
Abstract
HCM has long been considered the most frequent cause of death in athletes, and reason for disqualification from sport. However, our perception of the impact of sports on HCM is largely based on anecdotal evidence. In this review, we provide a reappraisal of current knowledge relative to 1) the impact of sport on LV remodeling, and 2) on the clinical outcome of HCM in athletes. 1) The limited available evidence argues against the hypothesis that intensive exercise conditioning may trigger and/or worsen the development of LV hypertrophy or cause changes in LV function in adult HCM athletes. 2) Recent observations challenge the concept of a detrimental effect of sport on HCM clinical course. The Reset-HCM study showed that 16-week moderate-intensity exercise resulted in a small, significant increase in exercise capacity and no adverse events. In a cohort of 88 low-risk HCM athletes followed for a 7-year period, survival analyses showed no difference in mortality between HCM who discontinued or pursued vigorous exercise programmes. Further reassurance was provided by the ICD Sports Safety Registry. Clinical implications: At present, patients' attitude to sport participation is highly variable, based on social and legal backgrounds surrounding medical practice in different countries. The shared-decision-making as suggested by current US and European guidelines allows the physician to deliver a tailored and more liberal advice. Physicians should be aware of the changing paradigm relative to exercise and sport prescription for HCM and promote active lifestyle as an integral component of modern management of HCM patients.
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Affiliation(s)
| | - Sharlene Day
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
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9
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Katyal A, Li COY, Franciosi S, Sanatani S. The safety of sports in children with inherited arrhythmia substrates. Front Pediatr 2023; 11:1151286. [PMID: 37124180 PMCID: PMC10132466 DOI: 10.3389/fped.2023.1151286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/22/2023] [Indexed: 05/02/2023] Open
Abstract
Sudden cardiac death (SCD) is a rare and devastating event in children and remains a leading cause of death in young athletes. Channelopathies and cardiomyopathies, in particular long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), hypertrophic cardiomyopathy (HCM), and arrhythmogenic cardiomyopathy (ACM) are associated with exercise-related SCD. Implantable cardioverter-defibrillators (ICDs) are often placed for secondary prevention for athletes with cardiomyopathy or channelopathy. There remains concern regarding the safety of return to participation with an ICD in place. Guidelines have historically recommended that patients with inherited heart rhythm disorders be restricted from competitive sports participation. Increasing evidence suggests a lower risk of exercise-related cardiac events in young athletes with inherited heart rhythm disorders. In this review, we highlight current knowledge, evolving guidelines, and present a multidisciplinary approach involving shared decision-making and appropriate planning for safe sports participation of children with inherited heart rhythm disorders.
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10
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Abela M, Grech V, Sammut MA. Automated external defibrillators and basic life support practices in secondary schools: a nationwide study. Cardiol Young 2022; 33:1-4. [PMID: 36373237 DOI: 10.1017/s1047951122003572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM Cardiac arrest prevention in schools has recently gained momentum. The survival benefit in schools who have access to defibrillators is clear, with far better survival outcomes in children or adults who sustain a cardiac arrest on school grounds. The main objectives of this study were to assess sudden cardiac arrest prevention in Maltese schools, specifically the availability of defibrillators and staff competence in delivering resuscitation. METHODOLOGY AND RESULTS An online-based questionnaire was distributed to all secondary schools across the Maltese archipelago. Data were collected, tabulated, and analysed using SPSS V.23. Most schools (n = 40, 74.1%) completed the questionnaire. Two schools documented a cardiac arrest in the past 10 years. 87.5% agreed that cardiac arrest prevention is an important health topic. Most have a defibrillator on the premises (n = 37, 92.5%). Only one defibrillator is usually available (n = 27, 75.0%). Despite the majority claiming its ease of accessibility (n = 35, 97.2%), most were not available on every floor (n = 37, 97.2%). Only one-third were close to a sporting facility (n = 11, 30.6%). Schools do not organise regular resuscitation courses (n = 21, 58.3%), with eight schools having five or more certified staff members (23.5%). The number of defibrillators did not influence the frequency of resuscitation courses at school (p = 0.607), and there was no association with the number of certified individuals (p = 0.860). CONCLUSION Defibrillators are not readily available at secondary schools and are often installed in low-risk areas. Most schools have only one staff member certified in resuscitation. These factors should be addressed with urgency.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Malta
- Cardiology, University of Malta, Malta
| | - Victor Grech
- Depatment of Paediatrics, Mater Dei Hospital, Malta
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Tobert KE, Bos JM, Cannon BC, Ackerman MJ. Outcomes of Athletes With Genetic Heart Diseases and Implantable Cardioverter-Defibrillators Who Chose to Return to Play. Mayo Clin Proc 2022; 97:2028-2039. [PMID: 35985858 DOI: 10.1016/j.mayocp.2022.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/17/2022] [Accepted: 03/23/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate outcomes for athletes with a genetic heart disease (GHD) and an implantable cardioverter-defibrillator (ICD) after return-to-play (RTP) approval. PATIENTS AND METHODS We conducted a retrospective review of athletes with GHD and an ICD who were evaluated and treated in Mayo Clinic's Genetic Heart Rhythm Clinic between July 2000 and July 2020. Data on frequency of GHD-associated breakthrough cardiac events (BCEs), inappropriate shocks, and ICD-related complications were collected and analyzed. RESULTS There were 125 (57 [45.6%] female) GHD-positive athletes with an ICD (mean age at RTP was 19.8±11.6 years); 56 of 125 (44.8%) had long QT syndrome. Overall, 42 ventricular fibrillation-terminating ICD therapies were given to 23 athletes (18.4%) over an average follow-up of 3.6±3.5 years. Athletes with an ICD were more likely to experience a BCE during athletic follow-up (n=28 of 125, 22.4%) compared with those without an ICD (n=4 of 533, 0.8%; P<.0001). The BCE rate for athletes with ICDs was 6.3 events per 100 athlete-years of follow-up; this included 5.1 ventricular fibrillation-terminating events per 100 athlete-years compared with 0.3 BCEs per 100 patient-years for athletes without ICDs. In total, 6 (4.8%) athletes experienced at least one inappropriate shock (1.34 per 100 athlete-years) and 28 (29.6%) athletes had at least one other device-related complication (5.02 per 100 patient-years). However, none of these other complications occurred during sports. CONCLUSION This 20-year single-center study provides the longest spanning retrospective review of outcomes for athletes with ICDs given RTP approval. For athletes with GHD and an ICD, no sports-associated deaths or reports of sports-related ICD damage occurred.
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Affiliation(s)
- Kathryn E Tobert
- Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - J Martijn Bos
- Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Bryan C Cannon
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, MN, USA
| | - Michael J Ackerman
- Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Windland Smith Rice Genetic Heart Rhythm Clinic, Mayo Clinic, Rochester, MN, USA
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12
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Kay B, Lampert R. Devices and Athletics. Cardiol Clin 2022; 41:81-92. [DOI: 10.1016/j.ccl.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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13
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Abstract
Individuals with HCM have historically been held from participation in sports beyond mild-intensity exercise. Exercise improves functional capacity and indices of cardiac function even in those with HCM. Emerging data have demonstrated the safety of exercise in individuals with HCM. Improvement in risk stratification and a shared decision-making approach has led to a guideline endorsement for HCM providers to develop an informed plan for exercise and competitive athletics among the HCM population.
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Affiliation(s)
- Matthew W Martinez
- Department of Cardiovascular Medicine, Atlantic Health, Morristown Medical Center, Morristown, NJ 07960, USA; Sports Cardiology and Hypertrophic Cardiomyopathy.
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14
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Franciosi S, Abrams DJ, Ingles J, Sanatani S. Sudden Cardiac Arrest in the Paediatric Population. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:45-59. [PMID: 37969243 PMCID: PMC10642157 DOI: 10.1016/j.cjcpc.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/03/2022] [Indexed: 11/17/2023]
Abstract
Sudden cardiac arrest in the young is a rare event with a range of potential causes including cardiomyopathies, ion channelopathies, and autonomic nervous system dysfunction. Investigations into the cause involve a multidisciplinary team, including cardiologists, geneticists, and psychologists. In addition to a detailed medical history, family history and circumstances surrounding the event are important in determining the cause. Clinical investigations including an electrocardiogram are fundamental in diagnosis and should be interpreted cautiously because some children may have atypical presentations and an evolving phenotype. The potential for misdiagnosis exists that could lead to incorrect long-term management strategies. If an inherited condition is suspected, genetic testing of the patient and cascade screening of family members is recommended with genetic counselling and psychological support. Medical management is left to the treating physician acknowledging that a clear diagnosis cannot be made in approximately half of cases. Secondary prevention implantable defibrillators are widely deployed but can be associated with complications in young patients. A plan for safe return to activity is recommended along with a proper transition of care into adulthood. Broad screening of the general population for arrhythmia syndromes is not recommended; preventative measures include screening paediatric patients for risk factors by their primary care physician. Several milestone events or activities that take place in youth could be used as opportunities to promote safety. Further work into risk stratification of this paediatric population through patient registries and greater awareness of cardiopulmonary resuscitation and automated external defibrillator use in saving lives is warranted.
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Affiliation(s)
- Sonia Franciosi
- BC Children’s Hospital Heart Centre, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dominic J. Abrams
- Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jodie Ingles
- Centre for Population Genomics, Garvan Institute of Medical Research, and UNSW Sydney, Sydney, New South Wales, Australia
- Centre for Population Genomics, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Shubhayan Sanatani
- BC Children’s Hospital Heart Centre, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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15
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Chen CH, De Souza AM, Franciosi S, Harris KC, Sanatani S. Physical Activity in Paediatric Long QT Syndrome Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:80-85. [PMID: 38058492 PMCID: PMC10697215 DOI: 10.1016/j.cjcpc.2021.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 12/08/2023]
Abstract
Background Physical activity (PA) is important for cardiovascular health as well as social and emotional well-being of children. Patients with long QT syndrome (LQTS) often face PA restrictions and are often prescribed beta-blockers for disease management. The aim of this study was to determine if PA levels were lower in patients with LQTS compared with healthy controls. Methods Participants with LQTS from an inherited arrhythmia clinic completed the Physical Activity Questionnaire for Children and Adolescents (PAQ-C/A) and an exercise stress test. PAQ score (a general measure of PA for youth, unitless) and endurance time were compared with healthy controls. Results Twenty-three patients with LQTS completed the PAQ and had an exercise stress test within a year of having completed the PAQ. No difference was observed in PAQ scores between LQTS and control groups (LQTS: 2.3 ± 0.15 vs controls: 2.3 ± 0.18; P = 0.78). There was no effect of age on PA in patients with LQTS (P > 0.05), whereas PA significantly decreased in controls with age (eg, 11-12 vs 17-20 years: 3.2 ± 0.07 vs 1.5 ± 0.08, P = 0.005). Endurance time and heart rate at peak exercise were significantly lower in patients with LQTS compared with controls (11 ± 0.5 vs 15 ± 0.5 minutes, P < 0.0001; 169 ± 5 vs 198 ± 2 beats per minute, P < 0.0001). Conclusions Despite guideline recommendations restricting PA, risk of sudden cardiac death, and use of beta-blockers, our cohort of patients with LQTS reported similar PA levels as healthy controls.
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Affiliation(s)
- Chi Hung Chen
- Division of Cardiology, Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Astrid-Marie De Souza
- Division of Cardiology, Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia Franciosi
- Division of Cardiology, Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin C. Harris
- Division of Cardiology, Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shubhayan Sanatani
- Division of Cardiology, Department of Pediatrics, Children’s Heart Centre, BC Children’s Hospital, Vancouver, British Columbia, Canada
- Division of Cardiology, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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16
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Abstract
Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.
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Affiliation(s)
- Asterios Deligiannis
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelia Kouidi
- Laboratory of Sports Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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17
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Shah MJ, Silka MJ, Silva JNA, Balaji S, Beach CM, Benjamin MN, Berul CI, Cannon B, Cecchin F, Cohen MI, Dalal AS, Dechert BE, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril PJ, Karpawich PP, Kim JJ, Krishna MR, Kubuš P, LaPage MJ, Mah DY, Malloy-Walton L, Miyazaki A, Motonaga KS, Niu MC, Olen M, Paul T, Rosenthal E, Saarel EV, Silvetti MS, Stephenson EA, Tan RB, Triedman J, Bergen NHV, Wackel PL. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Developed in collaboration with and endorsed by the Heart Rhythm Society (HRS), the American College of Cardiology (ACC), the American Heart Association (AHA), and the Association for European Paediatric and Congenital Cardiology (AEPC) Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). JACC Clin Electrophysiol 2021; 7:1437-1472. [PMID: 34794667 DOI: 10.1016/j.jacep.2021.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
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Affiliation(s)
- Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California, USA.
| | | | | | | | - Monica N Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York University Grossman School of Medicine, New York, New York, USA
| | | | - Aarti S Dalal
- Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois, USA
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter P Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan, USA
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary C Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Melissa Olen
- Nicklaus Children's Hospital, Miami, Florida, USA
| | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | | | - Reina B Tan
- New York University Langone Health, New York, New York, USA
| | | | - Nicholas H Von Bergen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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18
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2021 PACES expert consensus statement on the indications and management of cardiovascular implantable electronic devices in pediatric patients. Cardiol Young 2021; 31:1738-1769. [PMID: 34338183 DOI: 10.1017/s1047951121003413] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
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19
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Boisson A, De La Villeon G, Huguet H, Abassi H, Pasquie JL, Lavastre K, Matecki S, Guillaumont S, Requirand A, Calderon J, Amedro P. Physical activity and aerobic fitness in children with inherited cardiac diseases. Arch Cardiovasc Dis 2021; 114:727-736. [PMID: 34756533 DOI: 10.1016/j.acvd.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/01/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Because of sports and exercise restrictions, children with inherited cardiac disease are at risk of physical deconditioning. Guidelines on sports participation in cardiovascular disease have become less restrictive over time, but their real-life application and behavioural impact have seldom been evaluated in children. AIMS We aimed to evaluate adherence to the 2020 European Society of Cardiology guidelines on sports and exercise in children with inherited cardiac arrhythmia and inherited cardiomyopathy; we also sought to evaluate their aerobic fitness, and the behavioural impact of inherited cardiac diseases on physical activity in children. METHODS Children aged 6-18 years with inherited cardiomyopathy or inherited cardiac arrhythmia were eligible for this cross-sectional study. Clinical, demographic and qualitative data were analysed. RESULTS A total of 32 children were included in the study (mean age 12.7±3.5 years). Most children (81.3%) complied with the 2020 European Society of Cardiology guidelines; they were physically active and had good overall aerobic fitness, with a mean peak oxygen uptake (VO2) value of 36.5±8.0mL/kg/min (84.0±17.2% of theoretical value). As a result of personal or parental behaviour, some children at risk of sudden cardiac death did not comply with the recommended upper limit of physical activity intensity, whereas others at low risk did not comply with the lower limit. CONCLUSION Most children with inherited cardiac arrhythmia or inherited cardiomyopathy complied with current 2020 European Society of Cardiology guidelines on sports cardiology and exercise in cardiovascular disease.
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Affiliation(s)
- Aymeric Boisson
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France
| | - Gregoire De La Villeon
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Paediatric Cardiology and Rehabilitation Unit, Saint-Pierre Institute, 34250 Palavas-Les-Flots, France
| | - Helena Huguet
- Clinical Research and Epidemiology Unit, CHU de Montpellier, University of Montpellier, 34295 Montpellier, France
| | - Hamouda Abassi
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Inserm, PhyMedExp, CNRS, University of Montpellier, 34295 Montpellier, France
| | - Jean-Luc Pasquie
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Inserm, PhyMedExp, CNRS, University of Montpellier, 34295 Montpellier, France
| | - Kathleen Lavastre
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France
| | - Stefan Matecki
- Inserm, PhyMedExp, CNRS, University of Montpellier, 34295 Montpellier, France; Department of Physiology, CHU de Montpellier, 34295 Montpellier, France
| | - Sophie Guillaumont
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Paediatric Cardiology and Rehabilitation Unit, Saint-Pierre Institute, 34250 Palavas-Les-Flots, France
| | - Anne Requirand
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France
| | - Johanna Calderon
- Paediatric and Congenital Cardiology Department, M3C Regional Reference Centre, University Hospital, 34295 Montpellier, France; Inserm, PhyMedExp, CNRS, University of Montpellier, 34295 Montpellier, France
| | - Pascal Amedro
- Department of Paediatric and Adult Congenital Cardiology, M3C National Reference Centre, Bordeaux University Hospital, 33604 Pessac, France; Inserm, U1045, IHU Liryc, Bordeaux Cardio-Thoracic Research Centre, Electrophysiology and Heart Modelling Institute, University of Bordeaux, Fondation Bordeaux Université, 33604 Pessac, France.
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20
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Sex-Specific Impacts of Exercise on Cardiovascular Remodeling. J Clin Med 2021; 10:jcm10173833. [PMID: 34501285 PMCID: PMC8432130 DOI: 10.3390/jcm10173833] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/21/2021] [Accepted: 08/21/2021] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular diseases (CVD) remain the leading cause of death in men and women. Biological sex plays a major role in cardiovascular physiology and pathological cardiovascular remodeling. Traditionally, pathological remodeling of cardiovascular system refers to the molecular, cellular, and morphological changes that result from insults, such as myocardial infarction or hypertension. Regular exercise training is known to induce physiological cardiovascular remodeling and beneficial functional adaptation of the cardiovascular apparatus. However, impact of exercise-induced cardiovascular remodeling and functional adaptation varies between males and females. This review aims to compare and contrast sex-specific manifestations of exercise-induced cardiovascular remodeling and functional adaptation. Specifically, we review (1) sex disparities in cardiovascular function, (2) influence of biological sex on exercise-induced cardiovascular remodeling and functional adaptation, and (3) sex-specific impacts of various types, intensities, and durations of exercise training on cardiovascular apparatus. The review highlights both animal and human studies in order to give an all-encompassing view of the exercise-induced sex differences in cardiovascular system and addresses the gaps in knowledge in the field.
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21
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Shah MJ, Silka MJ, Silva JA, Balaji S, Beach C, Benjamin M, Berul C, Cannon B, Cecchin F, Cohen M, Dalal A, Dechert B, Foster A, Gebauer R, Gonzalez Corcia MC, Kannankeril P, Karpawich P, Kim J, Krishna MR, Kubuš P, Malloy-Walton L, LaPage M, Mah D, Miyazaki A, Motonaga K, Niu M, Olen M, Paul T, Rosenthal E, Saarel E, Silvetti MS, Stephenson E, Tan R, Triedman J, Von Bergen N, Wackel P. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients. Heart Rhythm 2021; 18:1888-1924. [PMID: 34363988 DOI: 10.1016/j.hrthm.2021.07.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 01/10/2023]
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consenus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology, (ACC) and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate follow-up in pediatric patients.
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Affiliation(s)
- Maully J Shah
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Michael J Silka
- University of Southern California Keck School of Medicine, Los Angeles, California.
| | | | | | - Cheyenne Beach
- Yale University School of Medicine, New Haven, Connecticut
| | - Monica Benjamin
- Hospital de Pediatría Juan P. Garrahan, Hospital El Cruce, Hospital Británico de Buenos Aires, Instituto Cardiovascular ICBA, Buenos Aires, Argentina
| | | | | | - Frank Cecchin
- New York Univeristy Grossman School of Medicine, New York, New York
| | | | - Aarti Dalal
- Washington University in St. Louis, St. Louis, Missouri
| | | | - Anne Foster
- Advocate Children's Heart Institute, Chicago, Illinois
| | - Roman Gebauer
- Heart Centre Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Peter Karpawich
- University Pediatricians, Children's Hospital of Michigan, Detroit, Michigan
| | | | | | - Peter Kubuš
- Children's Heart Center, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | | | - Doug Mah
- Harvard Medical School, Boston, Massachussetts
| | - Aya Miyazaki
- Shizuoka General Hospital and Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | | | - Mary Niu
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | | | - Thomas Paul
- Georg-August-University Medical Center, Göttingen, Germany
| | - Eric Rosenthal
- Evelina London Children's Hospital and St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | - Reina Tan
- New York University Langone Health, New York, New York
| | - John Triedman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Nicholas Von Bergen
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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22
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Amedro P, Werner O, Abassi H, Boisson A, Souilla L, Guillaumont S, Calderon J, Requirand A, Vincenti M, Pommier V, Matecki S, De La Villeon G, Lavastre K, Lacampagne A, Picot MC, Beyler C, Delclaux C, Dulac Y, Guitarte A, Charron P, Denjoy-Urbain I, Probst V, Baruteau AE, Chevalier P, Di Filippo S, Thambo JB, Bonnet D, Pasquie JL. Health-related quality of life and physical activity in children with inherited cardiac arrhythmia or inherited cardiomyopathy: the prospective multicentre controlled QUALIMYORYTHM study rationale, design and methods. Health Qual Life Outcomes 2021; 19:187. [PMID: 34321045 PMCID: PMC8317438 DOI: 10.1186/s12955-021-01825-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Advances in paediatric cardiology have improved the prognosis of children with inherited cardiac disorders. However, health-related quality of life (QoL) and physical activity have been scarcely analysed in children with inherited cardiac arrhythmia or inherited cardiomyopathy. Moreover, current guidelines on the eligibility of young athletes with inherited cardiac disorders for sports participation mainly rely on expert opinions and remain controversial. Methods The QUALIMYORYTHM trial is a multicentre observational controlled study. The main objective is to compare the QoL of children aged 6 to 17 years old with inherited cardiac arrhythmia (long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, or arrhythmogenic right ventricular dysplasia), or inherited cardiomyopathy (hypertrophic, dilated, or restrictive cardiomyopathy), to that of age and gender-matched healthy subjects. The secondary objective is to assess their QoL according to the disease’s clinical and genetic characteristics, the level of physical activity and motivation for sports, the exercise capacity, and the socio-demographic data. Participants will wear a fitness tracker (ActiGraph GT3X accelerometer) for 2 weeks. A total of 214 children are required to observe a significant difference of 7 ± 15 points in the PedsQL, with a power of 90% and an alpha risk of 5%. Discussion After focusing on the survival in children with inherited cardiac disorders, current research is expanding to patient-reported outcomes and secondary prevention. The QUALIMYORYTHM trial intends to improve the level of evidence for future guidelines on sports eligibility in this population. Trial registration ClinicalTrials.gov Identifier: NCT04712136, registered on January 15th, 2021 (https://clinicaltrials.gov/ct2/show/NCT04712136).
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Affiliation(s)
- Pascal Amedro
- Department of Paediatric and Adult Congenital Cardiology, M3C National Reference Centre, Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital, Avenue de Magellan, 33604, Pessac Cedex, France. .,INSERM, Bordeaux Cardio-Thoracic Research Centre, U1045, University of Bordeaux, Pessac, France. .,IHU Liryc, Electrophysiology and Heart Modelling Institute, Fondation Bordeaux Université, Pessac, France.
| | - Oscar Werner
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France
| | - Hamouda Abassi
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Aymeric Boisson
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France
| | - Luc Souilla
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France
| | - Sophie Guillaumont
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,Paediatric Cardiology and Rehabilitation Unit, Institut-Saint-Pierre, Palavas-Les-Flots, France
| | - Johanna Calderon
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Anne Requirand
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France
| | - Marie Vincenti
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Victor Pommier
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,Paediatric Cardiology and Rehabilitation Unit, Institut-Saint-Pierre, Palavas-Les-Flots, France
| | - Stefan Matecki
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Gregoire De La Villeon
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France.,Paediatric Cardiology and Rehabilitation Unit, Institut-Saint-Pierre, Palavas-Les-Flots, France
| | - Kathleen Lavastre
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, Montpellier University Hospital, Montpellier, France
| | - Alain Lacampagne
- PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Marie-Christine Picot
- Epidemiology and Clinical Research Department, Montpellier University Hospital, Montpellier, France
| | - Constance Beyler
- Paediatric Cardiology and Physiology Department, Robert Debré University Hospital, University of Paris, AP-HP, Paris, France
| | - Christophe Delclaux
- Paediatric Cardiology and Physiology Department, Robert Debré University Hospital, University of Paris, AP-HP, Paris, France
| | - Yves Dulac
- Paediatric Cardiology Department, M3C Regional Reference Centre, Toulouse University Hospital, Toulouse, France
| | - Aitor Guitarte
- Paediatric Cardiology Department, M3C Regional Reference Centre, Toulouse University Hospital, Toulouse, France
| | - Philippe Charron
- Department of Cardiology, National Reference Centre for Inherited Cardiomyopathy, University of Paris, AP-HP, Paris, France
| | - Isabelle Denjoy-Urbain
- Department of Cardiology, National Reference Centre for Inherited Cardiomyopathy, University of Paris, AP-HP, Paris, France
| | - Vincent Probst
- Department of Cardiology, National Reference Centre for Inherited Cardiac Arrhythmia, L'institut du thorax, INSERM, CNRS, University of Nantes, Nantes University Hospital, Nantes, France
| | - Alban-Elouen Baruteau
- Department of Pediatric Cardiology and Pediatric Cardiac Surgery, L'Institut du Thorax, INSERM, CNRS, University of Nantes, Nantes University Hospital, Nantes, France
| | - Philippe Chevalier
- Department of Congenital Cardiology, National Reference Centre for Inherited Cardiac Arrhythmia, University of Lyon, Lyon University Hospital, Lyon, France
| | - Sylvie Di Filippo
- Department of Congenital Cardiology, National Reference Centre for Inherited Cardiac Arrhythmia, University of Lyon, Lyon University Hospital, Lyon, France
| | - Jean-Benoit Thambo
- Department of Paediatric and Adult Congenital Cardiology, M3C National Reference Centre, Haut-Lévêque Cardiology Hospital, Bordeaux University Hospital, Avenue de Magellan, 33604, Pessac Cedex, France.,INSERM, Bordeaux Cardio-Thoracic Research Centre, U1045, University of Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modelling Institute, Fondation Bordeaux Université, Pessac, France
| | - Damien Bonnet
- Paediatric Cardiology Department, Necker-Enfants malades, M3C National Reference Centre, University of Paris, AP-HP, Paris, France
| | - Jean-Luc Pasquie
- Cardiology Department of Cardiology, Regional Reference Centre for Inherited Cardiac Arrhythmia, Montpellier University Hospital, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
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23
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2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients. Indian Pacing Electrophysiol J 2021; 21:367-393. [PMID: 34333141 PMCID: PMC8577100 DOI: 10.1016/j.ipej.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consensus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology (ACC), and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate CIED follow-up in pediatric patients.
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Zorzi A, Cipriani A, Bariani R, Pilichou K, Corrado D, Bauce B. Role of Exercise as a Modulating Factor in Arrhythmogenic Cardiomyopathy. Curr Cardiol Rep 2021; 23:57. [PMID: 33961139 PMCID: PMC8105216 DOI: 10.1007/s11886-021-01489-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The review addresses the role of exercise in triggering ventricular arrhythmias and promoting disease progression in arrhythmogenic cardiomyopathy (AC) patients and gene-mutation carriers, the differential diagnosis between AC and athlete's heart and current recommendations on exercise activity in AC. RECENT FINDINGS AC is an inherited heart muscle disease caused by genetically defective cell-to-cell adhesion structures (mainly desmosomes). The pathophysiological hallmark of the disease is progressive myocyte loss and replacement by fibro-fatty tissue, which creates the substrates for ventricular arrhythmias. Animal and human studies demonstrated that intense exercise, but not moderate physical activity, may increase disease penetrance, worsen the phenotype, and favor life-threatening ventricular arrhythmias. It has been proposed that in some individuals prolonged endurance sports activity may in itself cause AC (so-called exercise-induced AC). The studies agree that intense physical activity should be avoided in patients with AC and healthy gene-mutation carriers. However, low-to-moderate intensity exercise does not appear detrimental and these patients should not be entirely deprived from the many health benefits of physical activity.
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Affiliation(s)
- Alessandro Zorzi
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Riccardo Bariani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Kalliopi Pilichou
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy
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Sciarra L, Salustri E, Petroni R, Calò L, Delise P, Penco M, Romano S. Sport activity in patients with cardiac implantable electronic devices: evidence and perspectives. J Cardiovasc Med (Hagerstown) 2021; 22:335-343. [PMID: 32941324 DOI: 10.2459/jcm.0000000000001093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Demographic characteristics of patients with cardiac implantable electronic devices have significantly changed during the last few years, according to the ageing of the population and the consequent increase in the number of elderly individuals with indication for pacemaker implant and, on the other hand, to the increased number of young individuals implanted with an implantable cardioverter defibrillator for the primary prevention of sudden death. More and more often, both elderly and young patients ask the physician to deal with the device in their daily activities, which often include sport practice. This latter is advisable because of its recognized benefits on cardiovascular prevention, although there are many limitations for patients with a cardiac implantable electronic device. Hence, the need to balance the patient's request with the appropriate precautions emerging from existing evidence. The current article aims to provide an overview of the most recent data on this topic, derived from registries and observational studies. Over the years an attempt to standardize recommendations has been made, but robust evidence is still lacking. Substantial differences exist between countries based on their sports regulations. Official recommendations of European and American Scientific Societies are resumed. The future perspective is to obtain data to allow these patients a safer practice of sport activity also through technological advances in terms of device materials and programming improvement and the possibility of remote monitoring.
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Affiliation(s)
- Luigi Sciarra
- Department of Cardiology, Policlinico Casilino, Roma
| | - Elisa Salustri
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila
| | - Renata Petroni
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila
| | - Leonardo Calò
- Department of Cardiology, Policlinico Casilino, Roma
| | - Pietro Delise
- Division of Cardiology, Hospital 'P. Pederzoli', Peschiera del Garda, Italy
| | - Maria Penco
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila
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Duncker D, Ding WY, Etheridge S, Noseworthy PA, Veltmann C, Yao X, Bunch TJ, Gupta D. Smart Wearables for Cardiac Monitoring-Real-World Use beyond Atrial Fibrillation. SENSORS (BASEL, SWITZERLAND) 2021; 21:2539. [PMID: 33916371 PMCID: PMC8038592 DOI: 10.3390/s21072539] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 01/17/2023]
Abstract
The possibilities and implementation of wearable cardiac monitoring beyond atrial fibrillation are increasing continuously. This review focuses on the real-world use and evolution of these devices for other arrhythmias, cardiovascular diseases and some of their risk factors beyond atrial fibrillation. The management of nonatrial fibrillation arrhythmias represents a broad field of wearable technologies in cardiology using Holter, event recorder, electrocardiogram (ECG) patches, wristbands and textiles. Implementation in other patient cohorts, such as ST-elevation myocardial infarction (STEMI), heart failure or sleep apnea, is feasible and expanding. In addition to appropriate accuracy, clinical studies must address the validation of clinical pathways including the appropriate device and clinical decisions resulting from the surrogate assessed.
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Affiliation(s)
- David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool L1 8JX, UK; (W.Y.D.); (D.G.)
| | - Susan Etheridge
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84108, USA;
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55902, USA; (P.A.N.); (X.Y.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Christian Veltmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55902, USA; (P.A.N.); (X.Y.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - T. Jared Bunch
- Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84108, USA;
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool L1 8JX, UK; (W.Y.D.); (D.G.)
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Chang P, Beach C, Vinocur J, Das S. Expanding the Reach of Pediatric Transcatheter Pacing. J Innov Card Rhythm Manag 2021; 12:4487-4492. [PMID: 33939789 PMCID: PMC8081454 DOI: 10.19102/icrm.2021.120408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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(Athlete with pacemaker or cardioverter-defibrillator). COR ET VASA 2020. [DOI: 10.33678/cor.2020.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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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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