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

Assessing athletes beyond routine screening: Incorporating essential factors to optimize cardiovascular health and performance

The American Heart Association (AHA) has devised Life's Essential 8, a set of eight evidence-based health behaviors that play a crucial role in optimizing cardiovascular health and overall well-being. In addition to Life's Essential 8, enhanced screening for Cardiovascular-Kidney-Metabolic (CKM) Syndrome risk factors into routine athlete screening also provides a more comprehensive approach for ensuring athlete safety and long-term health. Incorporating Life's Essential 8 and CKM Syndrome metrics into athlete health evaluations will improve the sports performance of athletes and help optimize their long-term health.

Hypertrophic cardiomyopathy and competitive sports: let 'em play?

PURPOSE OF REVIEW

Hypertrophic cardiomyopathy (HCM) is one of the most common cardiovascular genetic conditions. Although most patients with HCM typically do well clinically, there is a small but real incidence of sudden cardiac death. A diagnosis of HCM was previously a reason for complete exclusion in sports, particularly competitive sports.However, many of these recommendations are based on expert consensus, and much data has been published in the last decade furthering the scientific knowledge in this area, and allowing athletes who may have been previously excluded the potential to participate in strenuous activities and competitive sports.

RECENT FINDINGS

With recent publications on participation in sports with HCM, as well as an emphasis on shared decision-making, more athletes with HCM are participating in competitive sports, even at a professional level. Even contact sports in the presence of an implantable cardioverter-defibrillator are no longer mutually exclusive in the current era.

SUMMARY

Previous guidelines were likely overly restrictive for patients with HCM. Although there is a risk of sudden death that cannot be ignored, the potential for shared decision making as well as medical guidance are entering a new era in all aspects of medicine, particularly in sports participation.

The role of coronary CT angiography in athletes

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

Palpitations in athletes: diagnosis, workup and treatment

Palpitations are a common reason for athletes to seek medical care. Although often benign, palpitations may serve as a harbinger for underling cardiac pathology. Given the unique challenges in this population, this review will serve to discuss the basic underlying pathophysiology, which may predispose athletes to palpitations. In addition, we will review the aetiologies, diagnostic evaluation, management and counselling strategies for some of the most common diagnoses seen in athletes.

What is the most appropriate age for the first cardiac screening of athletes?

For sporting organisations that conduct screening of athletes, there are very few consistent guidelines on the age at which to start. Our review found the total rate of sudden cardiac arrest or death is very low between the ages of 8-11 years (less than 1/100,000/year), increasing to 1-2/100,000/year in both elite athletes and community athletes aged 12-15 years and then steadily increases with age. The conditions associated with sudden cardiac death in paediatric athletes and young adult athletes are very similar with some evidence that death from coronary artery abnormalities occurs more frequently in athletes 10-14 years old. The decision when to begin a screening program involves a complex interplay between requirements and usual practices in a country, the rules of different leagues and programs, the age of entry into an elite program, the underlying risk of the population and the resources available. Given the incidence of sudden cardiac arrest or death in young people, we recommend beginning cardiac screening no earlier than 12 years (not later than 16 years). The risk increases with age, therefore, starting a program at any point after age 12 has added value. Importantly, anyone with concerning symptoms (e.g. collapse on exercise) or family history of an inherited cardiac condition should see a physician irrespective of age. Finally, no screening program can capture all abnormalities, and it is essential for organisations to implement a cardiac emergency plan including training on recognition and response to sudden cardiac arrest and prompt access to resuscitation, including defibrillators.

Associations between electrocardiographic findings and echocardiographic profiles in patients with hypertrophic cardiomyopathy

BACKGROUND

The relationships between electrocardiography (ECG) findings and echocardiographic profiles in patients with hypertrophic cardiomyopathy (HCM) are not fully understood.

METHODS

One hundred forty patients (mean age: 62.9 ± 15.3 years, 96 men) with HCM were studied. We assessed the associations between ECG findings and echocardiographic findings including maximum left ventricular wall thickness, HCM subtypes and distribution of left ventricular hypertrophy (LVH): the LV was divided into basal, mid, and apical segments by dividing it into thirds along the long axis.

RESULTS

In ECG, LVH by voltage criteria, abnormal Q wave, negative T wave, and giant negative T wave (GNT) were observed in 74 (53 %), 30 (21 %), 132 (94 %), and 25 (18 %) of the patients, respectively. In two groups with and without an LVH pattern according to voltage criteria in ECG, there were no significant differences in maximum LV wall thickness, subtype of HCM, and distribution of LVH. Regarding an abnormal Q wave, the proportion of patients with LVH in the basal segment was significantly higher in patients with an abnormal Q wave than in patients without an abnormal Q wave (87 % vs 61 %, p = 0.008). An abnormal Q wave was not observed in patients with LVH confined to the apex. Patients with a GNT included patients with LVH located at only the apex (apical HCM), LVH from the mid segment to apex, and LVH from the base to apex. No GNT was found in patients with hypertrophy located in the upper region from the base to mid segment of the LV.

CONCLUSIONS

In patients with HCM, there was no significant correlation between the presence of LVH by voltage criteria in ECG and echocardiographic findings. An abnormal Q wave was associated with disproportionate hypertrophy of the basal wall and a GNT reflected the presence of LVH in the apical segment.

[Place of the electrocardiogram in the visit of non-contra-indication to the practice of competitive sports between the ages of 12 and 35 : Survey of physicians who are members of the Guinean Association of Sports Physicians]

INTRODUCTION

An electrocardiogram (ECG), combined with a well-conducted clinical examination, is more effective than the clinical examination alone in detecting underlying cardiac pathologies in athletes. The aim of this study was to evaluate the use of ECGs by physicians who are members of the Guinean Association of Sports Physicians, during the non-contraindication visit for competitive sports between the ages of 12 and 35.

METHODOLOGY

We conducted a web-survey from July 15 to August 15, 2023. A survey form was created on "Google Docs" and pre-tested. It was then broadcast on all the communication networks used by these doctors. The data were secured using "Google Drive" software. Analyses were performed using SPSS version 20 software.

RESULTS

Of the 51 included, 74.51% said they had received at least one training session on ECG interpretation for athletes. All of them either requested or performed an ECG at least once in a while, as part of the check-up for non-contraindication to competitive sport. The ECG was systematic, according to 72.55% of doctors. Three quarters referred to a sports cardiologist in the event of an abnormal ECG, 66.67% to a cardiology resident and 58.82% to a cardiologist. In the absence of an ECG, the presence of functional signs on exertion, the notion of a family history of cardiovascular disease and the presence of at least two cardiovascular risk factors were the main reasons for seeking an opinion.

CONCLUSION

A resting ECG is carried out almost systematically by doctors who are members of the Guinean Association of Sports Doctors, as part of the check-up for non-contraindication to practising sport.

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

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

Exercise After Acute Myocarditis: When and How to Return to Sports

Myocarditis is an inflammatory disease of the myocardium secondary to infectious and noninfectious insults. The most feared consequence of myocarditis is sudden cardiac death owing to electrical instability and arrhythmia. Typical presenting symptoms include chest pain, dyspnea, palpitations and/or heart failure. Diagnosis is usually made with history, electrocardiogram, biomarkers, echocardiogram, and cardiac MRI (CMR). Application of the Lake Louise criteria to CMR results can help identify cases of myocarditis. Treatment is usually supportive with medical therapy, and patients are recommended to abstain from exercise for 3 to 6 months. Exercise restrictions may be lifted after normalization on follow-up testing.

Cardiac cycle timing and contractility following acute sport-related concussion

Cardiac sequelae following sport-related concussion are not well understood. This study describes changes in the cardiac cycle timing intervals and contractility parameters during the acute phase of concussion. Twelve athletes (21 ± 2 years, height = 182 ± 9 cm, mass = 86 ± 15 kg, BMI = 26 ± 3 kg/m2) were assessed within 5 days of sustaining a diagnosed concussion against their own pre-season baseline. A non-invasive cardiac sensor (LLA RecordisTM) was used to record the cardiac cycle parameters of the heart for 1 minute during supine rest. Cardiac cycle timing intervals (Isovolumic relaxation and contraction time, Mitral valve open to E wave, Rapid ejection period, Atrial systole to mitral valve closure, Systole, and Diastole) and contractile forces (Twist force and Atrial systole: AS) were compared. Systolic time significantly decreased during acute concussion (p = 0.034). Magnitude of AS significantly increased during acute concussion (p = 0.013). These results imply that concussion can result in altered systolic function.

Do five screening tools identify the same number of runners who require pre-exercise medical clearance? SAFER XXXIV

OBJECTIVES

Currently, there are five international screening tools that are recommended to identify individuals who require pre-exercise medical clearance to reduce the risk of medical encounters during exercise. Therefore, the aim was to determine the percentage of race entrants who are advised to obtain pre-exercise medical clearance and the observed agreement between these five different international pre-exercise medical screening tools.

METHODS

In all, 76,654 race entrants from the Two Oceans Marathon (2012-2015) that completed an online pre-race screening questionnaire. Five pre-exercise medical screening tools (American Heart Association (AHA), pre-2015 American College of Sport Medicine (ACSM), post-2015 ACSM, Physical Activity Readiness Questionnaire (PAR-Q), and the European Association of Cardiovascular Prevention and Rehabilitation (EACPR)) were retrospectively applied to all participants. The % (95%CI) race entrants requiring medical clearance identified by each tool and the observed agreement between tools (%) was determined.

RESULTS

The % entrants requiring medical clearance varied from 6.7% to 33.9% between the five tools: EACPR (33.9%; 33.5-34.3); pre-2015 ACSM (33.9%; 33.5-34.3); PAR-Q (23.2%; 22.9-23.6); AHA (10.0%; 9.7-10.2); post-2015 ACSM (6.7%; 6.5-6.9). The observed agreement was highest between the pre-2015 ACSM and EACPR (35.4%), for pre-2015 ACSM and PAR-Q (24.8%), PAR-Q and EACPR (24.8%), and lowest between the post-2015 ACSM and AHA (4.1%).

CONCLUSION

The percentage of race entrants identified to seek medical clearance (and observed agreement) varied considerably between pre-exercise medical screening tools. Further research should determine which tool has the best predictive ability in identifying those at higher risk of medical encounters during exercise.

Catastrophic Sports Injuries: Causation and Prevention

➤ Catastrophic injuries in U.S. high school and college athletes are rare but devastating injuries.➤ Catastrophic sports injuries are classified as either traumatic, caused by direct contact during sports participation, or nontraumatic, associated with exertion while participating in a sport.➤ Football is associated with the greatest number of traumatic and nontraumatic catastrophic injuries for male athletes, whereas cheerleading has the highest number of traumatic catastrophic injuries and basketball has the highest number of nontraumatic catastrophic injuries for female athletes.➤ The incidence of traumatic catastrophic injuries for all sports has declined over the past 40 years, due to effective rule changes, especially in football, pole-vaulting, cheerleading, ice hockey, and rugby. Further research is necessary to reduce the incidence of structural brain injury in contact sports such as football.➤ The incidence of nontraumatic catastrophic injuries has increased over the last 40 years and requires additional research and preventive measures. Avoiding overexertion during training, confirming sickle cell trait status in high school athletes during the preparticipation physical examination, and developing cost-effective screening tools for cardiac abnormalities are critical next steps.

Mortality trends, disparities, and social vulnerability in cardiac arrest mortality in the young: A cross-sectional analysis

BACKGROUND

Cardiac arrest (CA) is a leading cause of death in the United States (US). Social determinants of health may impact CA outcomes. We aimed to assess mortality trends, disparities, and the influence of the social vulnerability index (SVI) on CA outcomes in the young.

METHODS

We conducted a cross-sectional analysis of age-adjusted mortality rates (AAMRs) related to CA in the United States from the Years 1999 to 2020 in individuals aged 35 years and younger. Data were obtained from death certificates and analyzed using log-linear regression models. We examined disparities in mortality rates based on demographic variables. We also explored the impact of the SVI on CA mortality.

RESULTS

A total of 4792 CA deaths in the young were identified. Overall AAMR decreased from 0.20 in 1999 to 0.14 in 2020 with an average annual percentage change of -1.3% (p = .001). Black (AAMR: 0.30) and male populations (AAMR: 0.14) had higher AAMR compared with White (AAMR: 0.11) and female (AAMR: 0.11) populations, respectively. Nonmetropolitan (AAMR: 0.29) and Southern (AAMR: 0.26) regions were also impacted by higher AAMR compared with metropolitan (AAMR: 0.11) and other US census regions, respectively. A higher SVI was associated with greater mortality risks related to CA (risk ratio: 1.82 [95% CI, 1.77-1.87]).

CONCLUSIONS

Our analysis of CA in the young revealed disparities based on demographics, with a decline in AAMR from 1999 to 2020. There is a correlation between a higher SVI and increased CA mortality risk, highlighting the importance of targeted interventions to address these disparities effectively.

MLP-RL-CRD: diagnosis of cardiovascular risk in athletes using a reinforcement learning-based multilayer perceptron

Objective.Pre-participation medical screening of athletes is necessary to pinpoint individuals susceptible to cardiovascular events.Approach.The article presents a reinforcement learning (RL)-based multilayer perceptron, termed MLP-RL-CRD, designed to detect cardiovascular risk among athletes. The model underwent training using a publicized dataset that included the anthropological measurements (such as height and weight) and biomedical metrics (covering blood pressure and pulse rate) of 26 002 athletes. To address the data imbalance, a novel RL-based technique was adopted. The problem was framed as a series of sequential decisions in which an agent classified a received instance and received a reward at each level. To resolve the insensitivity to the initialization of conventional gradient-based learning methods, a mutual learning-based artificial bee colony (ML-ABC) was proposed.Main Results.The model outcomes were validated against positive (P) and negative (N) ECG findings that had been labeled by experts to signify individuals 'at risk' and 'not at risk,' respectively. The MLP-RL-CRD approach achieves superior outcomes (F-measure 87.4%; geometric mean 89.6%) compared with other deep models and traditional machine learning techniques. Optimal values for crucial parameters, including the reward function, were identified for the model based on experiments on the study dataset. Ablation studies, which omitted elements of the suggested model, affirmed the autonomous, positive, stepwise influence of these components on performing the model.Significance.This study introduces a novel, effective method for early cardiovascular risk detection in athletes, merging reinforcement learning and multilayer perceptrons, advancing medical screening and predictive healthcare. The results could have far-reaching implications for athlete health management and the broader field of predictive healthcare analytics.

Comparative evaluation of an electrocardiogram workflow model for athletic cardiovascular screening: Primary care network versus sports cardiology interpretation

BACKGROUND

Electrocardiogram (ECG) testing in pre-participation screening (PPS) remains controversial due to its cost, resource dependency, and the potential for inaccurate interpretations. At most centres, ECGs are conducted internally by providers trained in athletic ECG interpretation. Outsourcing ECG requisitions to an athlete's primary care network (PCN) may reduce institutional demands. This study compared PCN-conducted athletic ECG interpretation to expert sports cardiology interpretation.

METHODS

This was a retrospective, single-centre chart-review study of all athletes who underwent cardiovascular PPS between 2017 and 2021. All athletes submitted an ECG with their screening package, which was conducted and interpreted within their PCN. All ECGs were reinterpreted by a sports cardiologist using the International Criteria (IC) for electrocardiographic interpretation in athletes. Overall, positive, and negative percent agreement were used to compare PCN-conducted ECG interpretation with IC interpretation.

RESULTS

A total of 740 athletes submitted a screening package with a valid ECG (mean age: 18.5 years, 39.6% female). PCN-conducted ECGs were interpreted by 181 unique physicians. Among 41 (5.5%) PCN-conducted ECGs that were initially interpreted as abnormal, only 5 (0.7%) were classified as abnormal according to the IC. All PCN-conducted ECGs reported as normal were also classified as normal according to the IC. The overall agreement between PCN-conducted and IC ECG interpretation was 95.1% (positive percent agreement: 100%, negative percent agreement: 95.1%).

CONCLUSIONS

Normal PCN-conducted athletic ECGs are interpreted with high agreement to the IC. Majority of PCN-conducted ECGs interpreted as abnormal are indeed normal as per the IC. These findings suggest that a PPS workflow model that outsources ECG requisitions to a PCN may be a reliable approach to PPS, all while reducing screening-related institutional costs and resource requirements.

Meta-analysis on the Effectiveness of ECG Screening for Conditions Related to Sudden Cardiac Death in Young Athletes

Controversy exists over the use of electrocardiograms (ECGs) in sports pre-participation screening. We performed a meta-analysis comparing the effectiveness of history and physical examination (H&P) with ECG at detecting both cardiac disease and sudden cardiac death-associated conditions (SCD-AC). Pre-participation studies published from 2015 to 2020 with athletes 10 to 35 years old were included. This yielded 28 011 athletes screened and 124 cardiac diagnoses, 103 of which were SCD-AC. A meta-analysis of log odds ratios (ORs) was conducted using a random-effects model. The ORs for the association between H&P and detecting both cardiac disease and SCD-AC were not statistically significant (OR = 3.4, P = .076; OR = 2.9, P = .078). The ORs for the association between ECG and detecting both cardiac disease and SCD-AC were statistically significant (60, P < .001; 148, P < .0001). In conclusion, the odds of detecting both cardiac disease and conditions related to SCD with ECG are greater than with H&P during sports pre-participation screening.

The cardiac preparticipation sports evaluation

PURPOSE OF REVIEW

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. Preparticipation cardiovascular screening aims to identify those at an increased risk of SCD. This review aims to provide a background of SCD in young athletes, to discuss the various screening recommendations of major medical societies, and to review recent evidence and current practice.

RECENT FINDINGS

Numerous studies have evaluated various preparticipation screening practices, particularly regarding the inclusion of ECG as part of an initial evaluation to identify conditions with an increased risk of SCD. Some analyses have shown ECG inclusion to provide increased screening sensitivity and specificity, though others have shown no benefit when compared with evaluation with history and physical examination alone. Furthermore, in countries for which more extensive screening protocols have been employed, postimplementation statistics have not shown a significant decrease in SCD.

SUMMARY

SCD in young athletes primarily results from underlying cardiac disease. Various preparticipation screening recommendations exist globally, with the common goal of decreasing the rates of SCD by identifying youth at risk during sports participation. Current guidelines in the United States support universal preparticipation evaluation using history and physical examination, with cardiology referral if abnormalities are identified.

Congenital Long QT Syndrome and Cardiac Arrest in a Military Tactical Athlete

We present a case of a U.S. marine who experienced cardiac arrest during military Special Forces underwater diving exercises whose evaluation revealed congenital long QT syndrome. This case highlights the expanding role for systematic electrocardiogram screening in target athletic and military populations given their stress and tactical exposures. (Level of Difficulty: Advanced.).

Patterns of Electrocardiographic Abnormalities in Children with Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM), a common cardiomyopathy in children, is an important cause of morbidity and mortality. Early recognition and appropriate management are important. An electrocardiogram (ECG) is often used as a screening tool in children to detect heart disease. The ECG patterns in children with HCM are not well described.ECGs collected from an international cohort of children, and adolescents (≤ 21 years) with HCM were reviewed. 482 ECGs met inclusion criteria. Age ranged from 1 day to 21 years, median 13 years. Of the 482 ECGs, 57 (12%) were normal. The most common abnormalities noted were left ventricular hypertrophy (LVH) in 108/482 (22%) and biventricular hypertrophy (BVH) in 116/482 (24%) Of the patients with LVH/BVH (n = 224), 135 (60%) also had a strain pattern (LVH in 83, BVH in 52). Isolated strain pattern (in the absence of criteria for hypertrophy) was seen in 43/482 (9%). Isolated pathologic Q waves were seen in 71/482 (15%). Pediatric HCM, 88% have an abnormal ECG. The most common ECG abnormalities were LVH or BVH with or without strain. Strain pattern without hypertrophy and a pathologic Q wave were present in a significant proportion (24%) of patients. Thus, a significant number of children with HCM have ECG abnormalities that are not typical for "hypertrophy". The presence of the ECG abnormalities described above in a child should prompt further examination with an echocardiogram to rule out HCM.

Sudden cardiac arrest in athletes and strategies to optimize preparedness

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.

Chest Pain, Palpitations, and Syncope: Preventing Sudden Cardiac Death in Children

Sudden cardiac death is defined as an abrupt, unexpected death of cardiovascular cause with loss of consciousness within 1 hour of onset of symptoms. In an effort to prevent these events, clinicians need to recognize symptoms to identify at risk patients. There is often an overlap in symptoms of chest pain, palpitations, and syncope. The workup depends on the characteristics of these symptoms. The history and physical examination often provide adequate information, but additional testing and referral to pediatric cardiology are sometimes indicated.

The Role of Coronary CT Angiography in the Evaluation of Dual Left Anterior Descending Artery Prevalence and Subtypes: A Retrospective Multicenter Study

BACKGROUND

The aim of this multicenter study was to evaluate the prevalence and features of dual left anterior descending artery (LAD) subtypes using coronary CT angiography (CCTA).

METHODS

A retrospective multicenter analysis of 2083 CCTA from December 2020 to November 2022 was conducted to search for the presence and morphological features of dual LAD. The two classifications used were the updated classification of Spindola-Franco and the Jariwala classification. Statistical tests were conducted to evaluate the prevalence of dual LADs among sexes and its association with angina in patients without significant coronary stenoses and/or associated cardiac anomalies.

RESULTS

Dual LAD was observed in 124 (5.96%) patients analyzed. According to the Spindola-Franco revisited classification, type I dual LAD was the most common (71/124, 57.26%). According to the Jariwala classification, all cases were group I. In the general population, there was a higher prevalence of dual LAD among females (7.3% females vs. 5.1% males; p value: 0.04). No statistically significant difference was found in the prevalence of angina in the dual LAD population compared to the no dual LAD population (2.1% vs. 1.5%; p value: 0.10).

CONCLUSIONS

The acknowledgment and reporting of LAD duplication is helpful for an optimal management of coronary patients with this condition. Dual LAD was more frequent in the female population, mainly not related with angina. Myocardial bridge was more frequent in the dual LAD population than in the no dual LAD population.

Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023-Part 1. Pre-participation physical evaluation in young athletes

The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.

Living with Congenital Aortic Stenosis: Exercise Restriction, Patterns of Adherence, and Quality of Life

Modern consensus panel guidelines recommend restriction from most organized sports for patients with moderate or severe aortic stenosis (AS). However, there is little published data on how frequently physicians deviate from guidelines, how well patients adhere to exercise restrictions, or the effect of restriction on patient-reported quality of life. In this study, we surveyed 93 subjects with AS and their cardiologists regarding participation in organized sports, physical activity, weightlifting, and exercise restriction. Subjects completed the pediatric quality of life inventory (PedsQL) and the pediatric cardiac quality of life inventory (PCQLI). We found that subjects with severe AS (n = 3) were commonly, but not universally, restricted from organized sports (n = 2, 66%). Subjects with moderate AS (n = 40) were rarely restricted from organized sports (n = 6, 17%). No physician-specific characteristics were associated with increased likelihood of recommending exercise restriction. Subjects were more likely to be restricted if they were older (16 years vs. 13 years, p 0.02) and had moderate versus mild AS (p 0.013). PCQLI scores for teens and young adults with AS (age 13-25) were lower than a comparison group of patients with mild congenital heart disease. For all age groups, the PedsQL social functioning score was lower for subjects with exercise restriction (p 0.052). In summary, cardiologists apply consensus guidelines leniently when restricting patients with moderate/severe AS from organized sports and weightlifting. Patients with AS routinely adhere to exercise restriction recommendations. Children and young adults with AS and exercise restriction have lower QOL scores in the social functioning domain.

Rationale and design of the Birkebeiner Ageing Study - a prospective cohort study of older endurance athletes

BACKGROUND

While regular physical activity is associated with reduced mortality and morbidity in general populations, health outcomes and functional capacity related to upholding strenuous endurance exercise beyond the age of 65 years are only sparsely studied. The aim of this study is to assess associations of prolonged strenuous endurance sport practice with ageing, functional decline, morbidity and longevity among older recreational endurance athletes, during long-term follow-up.

METHODS

Prospective cohort study of older recreational endurance athletes in Norway. All skiers aged 65 years and older who participated in a long-distance endurance competition, the annual 54-km Birkebeiner cross-country ski race in 2009 or 2010, were invited. The participants answered an extensive baseline questionnaire about lifestyle habits, including leisure-time physical activity and endurance sport participation, diseases, medication use and physical and mental health, with follow-up questionnaires planned every fifth year until 2029. New participants may be invited with the aim to increase the study size. Endpoints such as all-cause and disease-specific mortality, incidence and cumulative prevalence of diseases, use of medication, physical and mental health and functional decline will be assessed subsequently. Out of 658 invited skiers (51 women), 551(84%) completed the baseline questionnaire and were included in the study. The mean age was 68.8 years (median 68, range 65- 90). At baseline, the participants had completed the Birkebeiner race for an average of 16.6 years and reported an average of 33.4 years of regular endurance exercise, with one out of five reporting at least 50 years of exercise. In all, 479 (90%) reported that they were still practicing leisure-time physical activity of moderate or vigorous intensity at least twice weekly. The prevalence of cardiovascular risk factors and diseases was low.

DISCUSSION

This prospective study of a cohort of recreational athletes exposed to prolonged and strenuous endurance exercise, could complement population-based studies by providing data on associations between life-long endurance sport participation, aging, functional decline and health outcomes during long-term follow-up.

Comparison of four electrocardiographic criteria for the detection of cardiac abnormalities in Singapore athletes

Introduction

Sudden cardiac death in athletes is a rare occurrence, the most common cause being hypertrophic cardiomyopathy, which increases the risk of sustained ventricular tachycardia or ventricular fibrillation. Most of these young athletes are asymptomatic prior to the cardiac arrest. Several electrocardiogram criteria such as the European Society of Cardiology group 2 Criteria changes, Seattle Criteria, Refined Criteria, and most recently the 2017 International Criteria, have sought to improve the accuracy of identifying these at-risk athletes during pre-participation screening while minimising unnecessary investigations for the majority of athletes at low risk.We aimed to compare the above four criteria in our Singapore athlete population to identify which criterion performed the best in detecting cardiac abnormalities on echocardiography.

Method

Out of 1,515 athletes included in Changi General Hospital, Singapore registry between June 2007 and June 2014, the electrocardiograms of 270 athletes with further cardiac investigations were analysed. We compared the above four electrocardiographic criteria to evaluate which performed best for detecting cardiac abnormalities on echocardiography in our Southeast Asian athlete population.

Results

The European Society of Cardiology, Seattle, Refined and 2017 International Criteria had a sensitivity of 20%, 0%, 20% and 5%, respectively; a specificity of 64%, 93%, 84% and 97%, respectively; a positive predictive value of 4%, 0%, 9% and 11%, respectively; and a negative predictive value of 91%, 92%, 93% and 93%, respectively for detecting abnormalities on echocardiography.

Conclusion

The latest 2017 International Criteria performed the best as it had the highest specificity and positive predictive value, joint highest negative predictive value, and lowest false positive rate.

Preparticipation Screening of Athletes: The Prevalence of Positive Family History

Sudden cardiac death (SCD) is a leading cause of death among athletes, and those with a positive family history (FH) of SCD and/or cardiovascular disease (CVD) may be at increased risk. The primary objective of this study was to assess the prevalence and predictors of positive FH of SCD and CVD in athletes using four widely used preparticipation screening (PPS) systems. The secondary objective was to compare the functionality of the screening systems. In a cohort of 13,876 athletes, 1.28% had a positive FH in at least one PPS system. Multivariate logistic regression analysis identified the maximum heart rate as significantly associated with positive FH (OR = 1.042, 95% CI = 1.027-1.056, p < 0.001). The highest prevalence of positive FH was found using the PPE-4 system (1.20%), followed by FIFA, AHA, and IOC systems (1.11%, 0.89%, and 0.71%, respectively). In conclusion, the prevalence of positive FH for SCD and CVD in Czech athletes was found to be 1.28%. Furthermore, positive FH was associated with a higher maximum heart rate at the peak of the exercise test. The findings of this study revealed significant differences in detection rates between PPS protocols, so further research is needed to determine the optimal method of FH collection.

[Correlation between changes in electrocardiographic and echocardiographic measurements and the nature of the sport practiced]

AIMS

Intense and regular sports practice leads to electrical and morphological cardiac remodeling. The aim of this study was to investigate a correlation between electrocardiographic and echocardiographic changes and the nature of the sport practiced.

METHODS

Retrospective study of the electrocardiogram and echocardiography of competitive athletes recruited in the medical-sports center of Sousse RESULTS: A total of 554 athletes were included. The mean age was 16.1 ± 2.9 years and 69% were male. The average training time was 5.8 hours per week. In the population, 319 (57.6%) subjects practiced an endurance sport vs. 235 (42.4%) subjects who practiced a resistance sport. Sinus bradycardia was noted in 70 (21.9%) endurance athletes vs. 30 (12.8%) resistance athletes (p = 0.005). Long PR interval was recorded in 12 endurance athletes vs. 3 cases among resistance athletes (p = 0.046). A right bundle branch bloc was reported more frequently among endurance athletes: 55 (17.2%) vs. 22 (9.4%); (p = 0.004). The mean value of the Sokolow-Lyon index was 31.51 ± 10.34 mm in endurance athletes vs. 29.72 ± 9.41 mm in resistance athletes (p = 0.037). Systolic ejection fraction was significantly lower in endurance athletes compared to resistance athletes (66.08 ± 4.73% vs. 68.1 ± 4.90%; p = 0.005).

CONCLUSIONS

This study showed that electrical abnormalities in athletes, considered physiological, are more frequent among endurance athletes. Therefore, sport-specific criteria need to be developed for a more appropriate approach to screening for electrical abnormalities in athletes.

Protecting the stars of tomorrow: do international cardiovascular preparticipation screening policies account for the paediatric athlete? A systematic review and quality appraisal

OBJECTIVE

(1) Identify and review current policies for the cardiovascular screening of athletes to assess their applicability to the paediatric population and (2) evaluate the quality of these policy documents using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool.

DESIGN

Systematic review and quality appraisal of policy documents.

DATA SOURCES

A systematic search of PubMed, MEDLINE, Scopus, Web of Science, SportDiscus and CINAHL.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

An article was included if it was a policy/position statement/guideline/consensus or recommendation paper relating to athletes and cardiovascular preparticipation screening.

RESULTS AND SUMMARY

Of the 1630 articles screened, 13 met the inclusion criteria. Relevance to paediatric athletes was found to be high in 3 (23%), moderate in 6 (46%) and low in 4 (31%), and only 2 provide tailored guidance for the athlete aged 12-18 years. A median 5 related citations per policy investigated solely paediatric athletes, with study designs most commonly being retrospective (72%). AGREEII overall quality scores ranged from 25% to 92%, with a median of 75%. The lowest scoring domains were rigour of development; (median 32%) stakeholder involvement (median 47%) and Applicability (median 52%).

CONCLUSION

Cardiac screening policies for athletes predominantly focus on adults, with few providing specific recommendations for paediatric athletes. The overall quality of the policies was moderate, with more recent documents scoring higher. Future research is needed in paediatric athletes to inform and develop cardiac screening guidelines, to improve the cardiac care of youth athletes.

Increasing Utilization of the Preparticipation Physical Evaluation

OBJECTIVE

The American Heart Association and American Academy of Pediatrics endorse the preparticipation physical evaluation (PPE) to screen student athletes for the risk of sudden cardiac arrest. We sought to identify barriers precluding its use and improve utilization.

METHODS

We analyzed documentation of PPE elements during well-care visits of patients aged 12 to 18 years from 5 primary care practices. Employing quality improvement (QI) methodology, we focused on improving PPE utilization in 1 practice by assessing the number of PPE elements addressed per chart. We expanded our QI project to 4 additional practices by using the same interventions but assessing the percentage of charts that had a complete PPE documented.

RESULTS

A baseline analysis of 5 targeted practices revealed an average of 3.5 of 14 PPE elements documented. Using plan-do-study-act cycles, PPE elements addressed increased from 2.5 to 14 over an 18-month period in the initial practice. By spreading successful interventions to 4 other practices, complete PPE utilization increased from a median baseline of 10.0% to a median of 70.0% over a 12-month period. Postintervention, 12 of 16 patients (75%) required additional follow-up with pediatric cardiology beyond the initial consultation, as compared with 2 of 14 patients (14%) preintervention.

CONCLUSION

The PPE is an underutilized but effective tool in screening student athletes for sudden cardiac arrest. QI methodology was helpful in increasing the use of PPE in the primary care setting.

Exercise After Acute Myocarditis: When and How to Return to Sports

Myocarditis is an inflammatory disease of the myocardium secondary to infectious and noninfectious insults. The most feared consequence of myocarditis is sudden cardiac death owing to electrical instability and arrhythmia. Typical presenting symptoms include chest pain, dyspnea, palpitations and/or heart failure. Diagnosis is usually made with history, electrocardiogram, biomarkers, echocardiogram, and cardiac MRI (CMR). Application of the Lake Louise criteria to CMR results can help identify cases of myocarditis. Treatment is usually supportive with medical therapy, and patients are recommended to abstain from exercise for 3 to 6 months. Exercise restrictions may be lifted after normalization on follow-up testing.

Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review

OBJECTIVE

To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources.

STUDY ELIGIBILITY CRITERIA

Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported.

METHODS

Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome.

RESULTS

A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results.

CONCLUSION

Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure.

PROSPERO REGISTRATION NUMBER

CRD42021272887.

Relationship between arm span to height ratio, aortic root diameter, and systolic blood pressure in collegiate athletes

Study objective

Sudden cardiac death is the most common cause of non-traumatic death in collegiate athletes. Marfan syndrome poses a risk for sudden cardiac death secondary to aortic root dilation leading to aortic dissection or rupture. Arm span to height ratio (ASHR) > 1.05 has been proposed as a screening tool for Marfan syndrome in pre-participation examinations (PPE) for collegiate athletes but limited data exists on the association between ASHR and aortic root diameter (ARD). This study examines the relationship between ASHR and ARD and assesses for predictors of ARD.

Design

Retrospective chart review.

Setting

National Collegiate Athletic Association Division I University.

Participants

793 athletes across thirteen sports between 2012 and 2022 evaluated with PPE and screening echocardiogram.

Interventions

Not applicable.

Main outcome measures

(1) Relationships between ASHR, SBP, BSA, and ARD amongst all athletes as well as stratified by ASHR >1.05 or ≤1.05 using univariate analysis. (2) Predictors of ARD using multivariate analysis using linear regression.

Results

143 athletes (18 %) had ASHRs > 1.05. Athletes with ASHR > 1.05 had higher ARD (2.99 cm) than athletes with ASHR ≤ 1.05 (2.85 cm). Weak correlations were noted between ASHR, ARD, and SBP. Multivariate analysis showed that BSA, male sex, and participation in swimming were predictors of ARD. ASHR was not predictive of ARD in regression analysis.

Conclusions

These findings showed a tendency towards higher ARD in athletes with ASHR >1.05 but this observation was not statistically significant in multivariate analysis.

Preparticipation State Cardiac Screening Forms for Athletes

BACKGROUND AND OBJECTIVES

Annual preparticipation physical evaluation (PPE) is used in the United States to screen adolescents for potential causes of sudden cardiac death. The American Heart Association recommends 14 screening elements of history and physical examination. This study sought to define the utilization of these screening elements by each of the 50 states before high school athletics.

METHODS

PPE forms were obtained from the public website of the high school athletics governing body in every state. Form content was analyzed to identify which of the 14 screening elements were explicitly fulfilled. Additional PPE forms provided by private/parochial schools, other professional societies, or independent groups were excluded from this study.

RESULTS

A total of 48 states (96%) had PPE forms posted online. The remaining 2 states (4%) deferred the specific method of PPE documentation to individual school districts and provided no standardized form. Of the 48 states providing PPE forms, 13 (27%) included all 14 American Heart Association screening elements. The median criteria included by each state was 11 (range 3-14). The 3 criteria most commonly absent were (1) the examination of femoral pulses to exclude coarctation (58%), (2) a family history of specific inherited cardiac disease (31%), and (3) personal history of hypertension (27%).

CONCLUSIONS

Annual preparticipation forms are important screening tools. Only a minority of states include all 14 cardiac screening elements recommended by the American Heart Association.

The association between marathon running and high-sensitivity cardiac troponin: A systematic review and meta-analysis

BACKGROUND

Marathon running is an extreme sport with a distance of about 42 kilometers. Its relationship to high-sensitivity cardiac troponin (hs-cTn) remains controversial.

OBJECTIVE

As the gold standard for detecting myocardial injury, the trends of hs-cTn before and after a marathon were investigated and analyzed.

METHODS

A literature search was conducted in PubMed, EMBASE, and Cochrane Library databases by combing the keywords marathon and troponin, and studies regarding high-sensitivity cardiac troponin I (hs-cTnI) and high-sensitivity cardiac troponin T (hs-cTnT) concentrations before and after marathon running (not for half-marathon and ultra-marathon) were included. "Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group" were used to assess the risk of bias. Statistical analysis was performed using Review Manager, presenting data as mean values and 95% confidence intervals (CIs). Sensitivity analysis and subgroup analysis were performed if there was high heterogeneity among studies based on I2 statistic.

RESULTS

A total of 13 studies involving 824 marathoners were included in this systematic review and meta-analysis. Both hs-cTnI (MD 68.79 ng/L, [95% CI 53.22, 84.37], p< 0.001) and hs-cTnT (MD 42.91 ng/L, [95% CI 30.39, 55.43], p< 0.001) were elevated after running a marathon, but the concentration of hs-cTnT returned to baseline after 72 to 96 h post-race (MD 0.11 ng/L, [95% CI -1.30, 1.52], p= 0.88). The results of subgroup analysis demonstrated that the 99th percentile upper reference limit of hs-cTnT might be the source of heterogeneity.

CONCLUSION

The concentrations of hs-cTnI and hs-cTnT were increased after marathon running, but the change of hs-cTnT is usually not seen as irreversible myocardial injury.

The safety of sports in children with inherited arrhythmia substrates

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.

Echocardiographic Evaluation of the Athlete's Heart: Focused Review and Update

PURPOSE OF REVIEW

The athlete's heart exhibits unique structural and functional adaptations in the setting of strenuous and repetitive athletic training which may be similarly found in pathologic states. The purpose of this review is to highlight the morphologic and functional changes associated with the athlete's heart, with a focus upon the insights that echocardiography provides into exercise-induced cardiac remodeling.

RECENT FINDINGS

Recent studies are aiming to investigate the long-term effects and clinical consequences of an athlete's heart. The "gray-zone" continues to pose a clinical challenge and may indicate scenarios where additional imaging modalities, or longitudinal follow-up, provide a definitive answer. Echocardiography is likely to remain the first-line imaging modality for the cardiac evaluation of elite athletes. Multimodality imaging combined with outcome and long-term follow-up studies both during training and after retirement in both men and women may help further clarify the remaining mysteries in the coming years.

Cardiac Arrest in a Softball Player Following a Collision

Commotio cordis is a rare cause of sudden cardiac arrest from blunt chest trauma; however, it is a diagnosis of exclusion. We present a case of sudden cardiac arrest in a collegiate athlete initially attributed to commotio cordis but in whom further history and workup revealed another rare condition. (Level of Difficulty: Advanced.)

Assessment of electrophysiological changes in the heart by analysing resting electrocardiografic recording and comparison with Seattle criteria in trained male 14-19 years aged volleyball players

Background: Cardiovascular arrest among athletes is prevalent in today's competitive world. As a result, a thorough and routine assessment is advised. The Seattle Criteria are one of the most widely accepted standards in the electrophysiological diagnosis and can reveal possible aberrant findings based on ECG values. Aim of the study: This study aims to investigate the heart's electrophysiological adaptations in trained male volleyball players. This comparison study used the Seattle Criteria to evaluate whether training has a beneficial or negative impact on the heart. Material and methods: In this study, 41 trained male volleyball players aged 14 to 19 were divided into three groups (14–15, 16–17, and 18–19). Each player's resting ECG was recorded and compared to the Seattle criteria. The Kruskal-Wallis nonparametric ANOVA was used, followed by the Mann-Whitney U test for significant outcomes. Results: The Q-T interval differed significantly between the three groups (p < 0.05). In Groups 2 and 3, ST depression was identified using ECG 23% and 8% of the time, respectively. In Groups 1, 2, and 3, ST elevation was detected in 60%, 62%, and 83% of ECGs, respectively. Group 1 had much longer ventricular depolarization and repolarization times. Sinus bradycardia, sinus arrhythmia, and early repolarization (ST elevation) are considered normal ECG findings in athletes, while a ST-segment depression (0.5 mm) is abnormal. Conclusions: It can be inferred that the adaptive aspects of the electrophysiological alterations in the heart as a result of training may help justify the effective workload and prevent cardiac failure in athletes.

Risk Factors for Sudden Death in Athletes, Is There a Role for Screening?

Purpose of Review

Sudden cardiac death (SCD) in a young athlete is an infrequent yet devastating event often associated with substantial media attention. Screening athletes for conditions associated with SCD is a controversial topic with debate surrounding virtually each component including the ideal subject, method, and performer/interpreter of such screens. In fact, major medical societies such as the American College of Cardiology/American Heart Association and the European Society of Cardiology have discrepant recommendations on the matter, and major sporting associations have enacted a wide range of screening policies, highlighting the confusion on this subject. This review seeks to summarize the literature in this area to address the complex and disputed subject of screening young athletes for SCD.

Recent Findings

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause myocarditis, which is one acquired cardiac disease associated with SCD. The coronavirus 2019 (COVID-19) pandemic has therefore resulted in an increased incidence of an otherwise less common condition, providing an expanded dataset for further study of this condition. Recent findings indicate that cardiac complications of athletes with myocardial involvement of SARS-CoV-2 infection are rare. Other contemporary work in SCD screening has been focused on the implementation of various screening protocols and measuring their effectiveness.

Summary

No universal consensus exists for athlete screening for conditions associated with SCD with varying guidelines and protocols across cardiology and sport-specific organizations. No screening program will prevent all SCD; however, small programs managed by physicians familiar with the examination of an athlete that carefully personalize screening to the individual may maximize detection of dangerous cardiac conditions while minimizing false positives.

Sports Participation and Physical Activity in Individuals with Heritable Thoracic Aortic Disease and Aortopathy Conditions

The evaluation and management of athletes with HTAD and aortopathy conditions requires shared decision-making encompassing the underlying condition, family history, aortic diameter, and type and intensity of sports and exercise. Mouse models of thoracic aortic disease show that low-to-moderate-level aerobic exercise can maintain aortic architecture and attenuate pathologic aortic root dilation. Although controlled trials in human are lacking, recreational physical activities performed at a low-to-moderate aerobic pace are generally low risk for most individuals with aortopathy conditions. High-intensity, competitive, and contact sports or physical activities are generally prohibited in individuals with aortopathy conditions.

Assessing the utility of screening electrocardiograms in paediatric patients following COVID-19

OBJECTIVE

To determine the utility of screening electrocardiograms after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children in detecting myocarditis related to coronavirus disease 2019 (COVID-19).

STUDY DESIGN

A retrospective chart review was performed at a large paediatric academic institution to identify patients with prior SARS-CoV-2 infection who received a screening electrocardiogram by their primary care providers and were subsequently referred for outpatient cardiology consultation due to an abnormal electrocardiogram. The outcomes were the results from their cardiology evaluations, including testing and final diagnoses.

RESULTS

Among 46 patients, during their preceding COVID-19 illness, the majority had mild symptoms, 4 were asymptomatic, and 1 had moderate symptoms. The median length of time from positive SARS-CoV-2 test to screening electrocardiogram was 22 days, and many electrocardiogram findings that prompted cardiology consultation were normal variants in asymptomatic adolescent athletes. Patients underwent frequent additional testing at their cardiology appointments: repeat electrocardiogram (72%), echocardiogram (59%), Holter monitor (11%), exercise stress test (7%), and cardiac MRI (2%). Five patients were incidentally diagnosed with CHD or structural cardiac abnormalities, and three patients had conduction abnormalities (pre-mature atrial contractions, pre-mature ventricular contractions, borderline prolonged QTc), although potentially incidental to COVID-19. No patients were diagnosed with myocarditis or ventricular dysfunction.

CONCLUSION

In a small cohort of children with prior COVID-19, who were primarily either asymptomatic or mildly symptomatic, subsequent screening electrocardiograms identified various potential abnormalities prompting cardiology consultation, but no patient was diagnosed with myocarditis. Larger multi-centre studies are necessary to confirm these results and to evaluate those with more severe disease.

Novel Hypertrophic Cardiomyopathy Diagnosis Index Using Deep Features and Local Directional Pattern Techniques

Hypertrophic cardiomyopathy (HCM) is a genetic disorder that exhibits a wide spectrum of clinical presentations, including sudden death. Early diagnosis and intervention may avert the latter. Left ventricular hypertrophy on heart imaging is an important diagnostic criterion for HCM, and the most common imaging modality is heart ultrasound (US). The US is operator-dependent, and its interpretation is subject to human error and variability. We proposed an automated computer-aided diagnostic tool to discriminate HCM from healthy subjects on US images. We used a local directional pattern and the ResNet-50 pretrained network to classify heart US images acquired from 62 known HCM patients and 101 healthy subjects. Deep features were ranked using Student’s t-test, and the most significant feature (SigFea) was identified. An integrated index derived from the simulation was defined as 100·log10(SigFea/2) in each subject, and a diagnostic threshold value was empirically calculated as the mean of the minimum and maximum integrated indices among HCM and healthy subjects, respectively. An integrated index above a threshold of 0.5 separated HCM from healthy subjects with 100% accuracy in our test dataset.

Experiences of Athletes with Arrhythmogenic Cardiac Conditions in Returning to Play

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.